Endo Strategy Session Intake Form
Name
*
First
Last
Email
*
Phone
*
Height
Weight
Date of Birth
Date Format: MM slash DD slash YYYY
Have you worked with a nutritionist, dietitian, or health coach before? If so, describe the experience.
What have you tried so far to relieve your symptoms?
Who is currently on your healing team?
What are your most bothersome symptoms?
List any foreseeable barrier that may prevent you from committing the next 4 months to improving your health.
What is the risk to you if you do not dedicate some time and effort now to optimizing your health?
How will you define success at the end of our work together? If you could wave a magic wand, what would you like to have happen in your health and life?
Do you have access to a computer, Internet, and a printer (to receive emails, schedule, print handouts, recipes, test results, have teleconferences, etc.)?*
YES
NO
* A computer is required (Ipad or phone is not accepted for the initial strategy session.)
Is there anything else I should know?
What are your top 3 questions for me?
In order to improve your health, how willing are you to: 5 (most wiling); 1 (not willing)
Significantly modify your diet
5 Most Willing
4
3
2
1 Not Willing
Take nutritional supplements each day
5 Most Willing
4
3
2
1 Not Willing
If necessary, keep a record of everything you eat daily
5 Most Willing
4
3
2
1 Not Willing
Modify your lifestyle (e.g. work demands, sleep habits)
5 Most Willing
4
3
2
1 Not Willing
Practice a relaxation technique
5 Most Willing
4
3
2
1 Not Willing
Engage in regular exercise
5 Most Willing
4
3
2
1 Not Willing
Have periodic lab tests to assess your progress
5 Most Willing
4
3
2
1 Not Willing
Take the needed time for yourself = Me-Time
5 Most Willing
4
3
2
1 Not Willing
How committed are you to solving this health challenge? (0 - not at all, 10 - extremely committed)
0
1
2
3
4
5
6
7
8
9
10