One on One Coaching Intake Form Congratulations on taking control of your health! Let’s get started! Name * First Name Last Name Email * Age List Medical Diagnoses Have you had any surgeries related to your digestive system? List any known food allergies or intolerances List medications and supplements List and describe your current digestive symptoms and how often you experience them Do you experience pain or discomfort during or after meals How would you describe your current diet? How often do you eat at restaurants or order takeout? How much water do you consume daily? Please describe your relationship with alcohol Do you smoke or take any other illicit drugs Rate your stress level 0-10 How many hours of sleep do you get per night on average? What are you exercise habits? Do you do any relaxation techniques? Yoga, meditation, breath work, etc What do you hope to achieve through our coaching? What is you goal in the next 4 weeks? What is your goal in the next 12 weeks? Thank you!