Get in touch. Nutrition Intake Form Nutrition Intake Form Name * First Name Last Name Email * What are your top 3 nutrition-related goals? * What's your current motivation level to reach these goals? (1-10 scale) What are the biggest challenges holding you back? Do you have any medical conditions (e.g., diabetes, hypertension, GI issues)? Are you currently taking any medications or supplements? (Please list below) Do you have any allergies or intolerances? How many meals do you typically eat per day? How often do you cook vs. eating out per week? Approximately how much water do you drink per day? How much caffine do you consumer in a week? How much alcohol do you drink in a week? Do you smoke? What has or hasn't worked for you in the past? What support or resources would help you the most? Any other information you'd like to share? Thank you! Personal Training Intake Form Personal Training Intake Form Name * First Name Last Name Email * What are your top fitness goals? * Are you looking to build Strenth Endurance Weight loss Mobility Something else How often do you currently exercise? Do you have any current or past injuries (back, knee, shoulder, etc.)? Do you want workouts at home, in the gym, or hybrid? What equipments do you have access to? On a scale of 1-10, how important is it to obtain your fitness goals? Any other information you'd like to share? Thank you! HIPAA Form HIPAA Name * First Name Last Name Phone (###) ### #### Date of Birth MM DD YYYY Information to Be Disclosed: Medical history Lab results Diagnoses or treatment Medications/supplements Nutrition-related health info Other Purpose of Authorization: I authorize the use or disclose of my protected health information to all DCODE to provide nutrition, fitness, and wellness services (Electronical signature required). Date MM DD YYYY Thank you!
