Coaching Intake Form Name* First Last Email* Phone*Date of Birth* Age*Coaching clients must be at least 18 years old.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about Your Tasty Life?*Ethnicity:*African-AmericanHispanicAsianNative AmericanCaucasianMarital Status:*SingleMarriedSeparatedDivorcedWidowedGender:*MaleFemaleOccupation:*Hours of work - From:* : HH MM AM PM To:* : HH MM AM PM GOALSWhat are your primary goals that you would like to achieve in the next 30 days?*What goals do you wish to accomplish in 6 months?*What goals do you wish to accomplish in 1 year?What would you identify as your biggest challenge to achieving your goals?*HEALTH HISTORYHave you ever been diagnosed with any of the following conditions?* High blood pressure High cholesterol Heart disease Diabetes Circulation problems Cancer Stomach or bowel problems Kidney disease Thyroid disease Dental problems Stroke Liver Disease Depression Sinus Problems Asthma Sleep Apnea Gout Anemia None Other health conditions:*Do you have food allergies or food intolerances?*NoYesIf Yes, what foods?Do you have cravings for certain foods?*NoYesIf Yes, what foods?Do you have symptoms after eating, such as belching, bloating, heartburn, gas, diarrhea?*NoYesHas your weight changed in the past year?*NoYesHow much (in Lbs.):*GainLossPresent Height:* : Ft In Present Weight:*What is the lowest weight you have maintained for one year since you were 21 years old?*LABORATORY VALUESNote recent blood sugar, cholesterol, or other values related to any of the above marked conditions:*List all medications and supplements you are currently taking.NAMEFREQUENCYDOSAGE LIFESTYLEDo you exercise?*NoYesTimes per weekMinutes per timeIf No, What prevents you from exercising?Energy (scale of 1-10, 10 is the best)*Stress (scale of 1-10, 10 is most severe)*FOOD HISTORYWhat is Your Typical Breakfast?*Typical Lunch?*Typical Dinner?*Typical Snacks?*How often do you eat/dine out weekly?How many cups of fluid do you drink each day?What types of fluid do you drink?*How many servings (1/2 cup of fresh fruit or 1 medium piece) of fruit do you eat a day?*How many servings of vegetable (1 cup leafy greens, 1/2 cup other veggies) do you eat a day?*How many servings bread (1 slice), cereal, pasta, rice, oats (1/2 cup) each day?*How many servings of sweets, cookies, cakes, candy, ice cream each week?*How many servings chips or salty snacks each week?*Do you drink alcohol?*NoYesTypes, amount, times per week:*What foods do you dislike? This iframe contains the logic required to handle AJAX powered Gravity Forms.