The Feel Good Project Intake Form – Isabel Dawkes Health

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Feel Good Project Intake Form

Before you get started with the Feel Good Project, you’ll need to spend a few minutes completing this intake form.

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Name

Date of Birth

Height

Weight (Estimated)

Occupation

Work EnvironmentOffice/work from home, desk based, active job, shift work etc

Home EnvironmentWho do you live with & where

Current Activity LevelsWhat type of exercise do you currently do, if any, and how often

How do you feel about exercise/activity?

Have you ever worked with a PT/coach?If yes, what was your experience like

How you ever followed a structured program before?

What are your current fitness goals?

Do you currently have a gym membership or any home equipment?

Do you have any current, ongoing or long standing injuries?If yes please give details

Do you have any current or ongoing or long standing health conditions?If yes please give details

Are you currently menstruating?

If yes, what was the date of your last period? And do you know how long your cycle is?

If no, are you pregnant, peri menopausal or menopausal?

Do you have any diagnosed or suspected hormone conditions? Such as PCOS, Endo, Hyper/hypo thyroid. If yes, please give details

Is there anything else we should know about your current health status?

How would you describe your relationship with food?

Please give examples of your typical breakfast

Please give examples of your typical lunch

Please give examples of your typical dinner

Please give examples of your typical snacks

How often do you eat out in a week?

What are some of your favourite foods?

What are some of your least favourite foods?

Have you previously followed a diet plan?If yes, please provide details

What are some of your biggest nutrition related questions?

What are some of your biggest food related struggles?

Are you currently following a specific way of eating?Ie calorie counting, low carb etc. If yes, please give details

What are you currenty biggest nutrition/food related goals?

What are some of the barriers you currently face in achieving your goals?

If there was one thing you could change today, what would it be?

What are you hoping to get from The Feel Good Project?