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Intake Form

This is a confidential intake form that will help me to get to know you better. Please fill out the form as thoroughly as possible. Thanks!

First Name

Last Name

Email

Phone

Date of birth

How young are you?

How were you born? *

Vaginal Deliver

C-Section

Did you take a lot of antibiotics as a child? *

Yes

No

Maybe

Place of birth

What is your height in centimeters?

Current weight:

Weight six months ago:

Would you like your weight to be different:

Yes

No

Maybe

Relationship status: *

Single

Married

Other

Do you have any children?

Occupation and hours of work per week:

Please list your main health concerns:

Please list your main healthy goals:

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/Injuries? This is at any point in your life. Please be specific.

How is/was the health of your mother?

How is/was the health of your father?

Do you sleep well at night? *

Yes

No

Maybe

Sometimes

How many hours?

Do you wake up at night?, if yes why?

Any pain, stiffness or swelling?

Are your periods regular? How many days is your flow?

How frequent do you have your period?

Are your periods painful or symptomatic? Please explain:

Reached or approaching menopause? please explain:

Birth control history:

Do you experience yeast infections or urinary track infections? Please explain:

Constipation/Diarrhea/Gas? please explain:

How often do you experience feeling bloated? *

Never

Occasionally

Sometimes

Often

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please explain:

What role does sports and exercise play in your life?

What foods did you eat as a child? Breakfast, lunch and dinner. Please be as specific as possible.

What's your food like these days? Breakfast, lunch and dinner. Kindly be as specific as possible.

Will family and friends be supportive of your desire to make food and/or lifestyle changes? *

Yes

No

Maybe

Do you cook?

What percentage of your food is home cooked?

Where do you get the rest of the food from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

How are your stress levels?

Select an option *

I AGREE

I DISAGREE

Full payments for all wellness packages must be completed on the first session.

The views and nutritional advice expressed by Cecilia Ayoub are not intended to be a substitute for conventional medical services. These sessions do not claim to “cure” disease, but simply to help you make physical and mental changes in your own body in order to help your body heal itself and reach healthy fitness goals. If you suspect that you have a medical problem, promptly contact your health care provider before beginning this or any other program. Always work with a qualified health care practitioner to ensure that this complementary approach suits your specific needs. If you are currently taking any medications or have been diagnosed with any serious illness, this program may not be suitable for you.

I agree

I disagree

Thanks for submitting!

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