30 Day Jumpstart Intake Questionnaire Name* First Last Birth Date* MM slash DD slash YYYY Phone*Email* What aspects of your health do you think need the most improvement?*What is your health goal(s)?*Why is this your health goal? What is your motivation?*Are you taking any steps to reach your goal?*Would you like any help creating action steps to achieve your goal?* Yes No Exercise, Nutrition, MindfulnessDo you exercise currently? If yes, how many hours per week.*No0-1 hours1-2 hours2-3 hours3-4 hours4+ hoursWhat type of exercises? (Select all that apply)* I don't exercise Cardio Strength Training Pilates Yoga Cycling/Biking Swimming Other What is your current nutrition like? Describe your meals and snacks for a typical day.*How many servings of fruits and vegetables do you eat per day?*0-23-45-67-89-1010+How many times per week do you eat out?*0-23-56-88+How many times per week do you prepare your own food?*0-34-89-1213-1617-21Do you currently plan your meals in advance?* Yes No Do you feel like cooking is a challenge?* Yes No Do you meditate or practice mindfulness?* Yes No General Health QuestionsWhat supplements (vitamins, minerals, probiotics, etc.) do you take? List frequency [daily, sometimes, irregularly, as needed]*List medications you are taking, including frequency.Do you have any diagnoses, physical limitations, or doctors orders that could affect your nutrition and exercise?* Yes No If yes, please describe... Do you have any questions? or is there anything you want me to know about your health?