Contact 1 — Intrinsic Destiny

Congratulations!

The fact that you’ve made it here means you’re already on your first step to better health + wellness. Fill out the form below to begin your journey.

Once I receive the form, I will review your answers and send you a link to book a complimentary 30 minute consultation.

You will have the opportunity to talk about your life, what you have always dreamed of and your health goals.

Name

First Name

Last Name

How often do you check email?

Phone

(###)

###

####

Age

Birthdate

YYYY

Place of Birth

Weight

Current Weight? Weight 6 Months Ago? Weight 1 Year Ago? Would you like your weight to be different, if so what?

Living Environment

Relationship Status? Where Do You Currently Live? Children? Pets?

Work Environment

Occupation? Hours of Work Per Week?

Health Information

List Your Main Health Concerns. Other Concerns? Goals? Any Serious Illnesses/Hospitalizations/Injuries?

Self Analysis

At what point in your life did you feel your best?

Family Health

How is/was the health of your mother? How is/was the health of your father? What is your ancestry?

Health Continued

Blood type? Any pains, stiffness or swelling? Constipation, diarrhea, gas? Allergies or sensitivities?

Sleep

How is your sleep? How many hours per night? Do you wake up at night? Why? Do you take naps?

Women's Health

Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Reached or approaching menopause? Explain. Birth control history? Do you experience yeast infections or urinary tract infections? Explain.

Medical Information

Do you take any supplements/medication? List. Any healers/helpers/therapies?

Activity

What role do you sports and exercise play in your life? How many days a week do you exercise? What kind?

Food History

What foods did you eat often as a child?

Food Diary Overview

Please provide a snapshot of three days of food.

Cooking

Do you cook? What % of your food is home cooked? Where do you get the rest of your meals from?

Support System

Will family, friends, partners, roommates be supportive of your desires to make food/lifestyle changes?

Cravings

Do you crave sugar, salt, caffeine, nicotine, alcohol, or any other addictions?

Technology Relationship

What is your phone screen time? Do you watch tv, how many hours per week? What is your relationship with social media?

Health Goals

The most important thing I can do to improve my health is ____. The number one thing holding me back from success is ____. Six months from now I would like to be ____. One year ____.

Connection to Intrinsic Destiny

What drew you in particularly to this program? Why do you want me to guide you in this journey? How serious are you about changing your lifestyle/nutrition? Anything else?