Initial Intake Welcome to your Initial Intake Please complete the entire Intake so that I can give you the best possible service. -Yolanda First Name Email Address 1. What Issues Do You Need My Help? Type 2 Diabetes Lack of Energy Sleep Problems Depression Other Hint 2. Are you currently under a Doctor's care? Yes No 3. Check Each Issue You Have Been diagnosed as Having Type 2 Diabetes Heart Issues Lung Issues Digestive Issues Kidney Issues Hint 4. Are You Currently Taking Prescribed Medications? Yes No 5. Are You Currently Taking Supplements? Yes No 6. Do You Engage in Regular Exercise? Yes No 7. How Much Water Do You Drink Daily? Less than 8oz 8oz-16oz 16oz-32oz More than 32oz 8. Do You... Drink Alcohol Smoke Drink Soda Drink Juice Drink Milk Drink Coffee Drink Team Engage in Regular Exercise Hint 9. Describe Your Favorite Food or Dinner Plate 10. How Many Meals Do You Eat Daily? 3 or less 4 - 6 More than 6 times 11. How Many Snacks Do You Eat Daily? 2 or less 3-5 More than 5 12. Do You Eat Vegetables? Never A few times a week Every Day 13. Are You Willing to Change Your Eating Habits or Make Different Lifestyle Choices? Yes No ** Please Enter the Security Code Below ** Time is Up! Time's up
