🌿 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

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Occupation

Emergency Contact (name +phone)

HEALTH & WELLNESS GOALS

1. What are your top 1–3 health goals right now?

2. What prompted you to seek help with food and wellness at this time?

3. Have you worked with a meal prep service, coach, or holistic practitioner before?

Yes

No

If yes, briefly explain:

🔹 CURRENT EATING HABITS

5. How many meals do you eat per day?

1

2

3

More than 3

7. Are there any foods you absolutely do NOT eat or dislike? (Please list)

8. What flavors or cuisines do you enjoy most?

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

If yes, explain

🔹 HEALTH HISTORY

10. Current diagnoses (if any):

11. Are you currently pregnant, postpartum, or breastfeeding?

Yes

No

🔹 MEDICATIONS & SUPPLEMENTS

12. Please list all current medications and dosages:

13. Do you take any supplements or herbs regularly?

🔹 FAMILY MEDICAL HISTORY

🔹 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

🔹 LIFESTYLE

20. How active are you weekly?

Sedentary

Light activity

Moderate

Very active

21. Do you smoke, drink alcohol, or use recreational drugs?

22. How would you rate your stress level?

Low

Moderate

High

Overwhelmed

23. What do you currently do to manage stress?

🔹 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

🔹 FINAL NOTES

27. Is there anything else you’d like us to know?

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