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🌿 Wellness Kitchen Client Intake Form

Let’s customize your wellness journey.


Please complete this form as thoroughly and honestly as possible. All information is confidential and used to create a personalized, holistic nutrition plan that supports your healing and lifestyle.

PERSONAL INFORMATION

Birthday
Month
Day
Year

 HEALTH & WELLNESS GOALS

3. Have you worked with a meal prep service, coach, or holistic practitioner before?
Yes
No

🔹 CURRENT EATING HABITS

Multi choice
5. How many meals do you eat per day?
6. Do you have any dietary preferences or restrictions?
Would you like to tell me anything else about your eating preferences? ( I don't like mushy food, I don't like my food to touch... etc)
Yes
No

🔹 HEALTH HISTORY

9. Please check any current or past conditions you have experienced:
11. Are you currently pregnant, postpartum, or breastfeeding?
Yes
No

🔹 MEDICATIONS & SUPPLEMENTS

🔹 FAMILY MEDICAL HISTORY

14. Do you have a family history of any of the following?

🔹 CURRENT ENERGETICS (Holistic Wellness Insight)

15. Describe your body temperature:
Always cold
Always warm
Fluctuates often
Neutral
16. Digestion after meals:
Feel full and energized
Bloated or gassy
Still hungry
Nausea or sluggish
17. Bowel movements per day:
1–2
3+
Irregular
Constipation
18. Energy levels throughout the day:
Consistent
Sluggish in the morning
Afternoon crashes
Wired at night
19. How would you describe your sleep?
Deep and restful
Interrupted
Trouble falling asleep
Not enough hours
Wake up tired

🔹 LIFESTYLE

20. How active are you weekly?
Sedentary
Light activity
Moderate
Very active
22. How would you rate your stress level?
Low
Moderate
High
Overwhelmed

🔹 BUDGET & PREFERENCES

24. What is your ideal budget for weekly meal prep?
$60–$80
$100–$150
$200+
Open to recommendations based on plan
25. How many meals per week would you like prepared?
3
5
7
Other
26. Are you interested in:

🔹 FINAL NOTES

28. How did you hear about Wellness Kitchen?

After you complete this form, You will will be directed to pay, schedule and confirm you consultation.

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