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ZEST Intake Form

First Name

Last Name

Phone number

Email address

Ok to contact for appt. reminders via:

Phone

Text

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Date of Birth

How did you hear about us?

Health care provider

WorkStrong

Friend

Facebook

Google

Instagram

Other

If other, please indicate specifically where you heard about us:

Street address

Street address 2 (optional)

City

State

Country

Zip code

Marital Status

Single / Not living with a partner

Living with a partner or spouse

Reason for visit

Height

Weight

Recent Weight Gain or Loss?

Yes, weight gain.

Yes, weight loss.

No.

If yes, how many pounds did you gain or lose, and in what period of time?

Desired Weight

Age last weighed desire weight

Top 3 Health or Nutrition Concerns

List any previous surgeries and the years they were completed.

List any current medical conditions:

List past medical conditions and actions taken for treatment:

List any physical activity you do during the week, the duration, and frequency (times per week)

Do you use tobacco or nicotine?

Yes

Once in awhile

If yes, how long have you used tobacco/nicotine?

Do you drink alcohol?

Yes, 1-3 drinks per week.

Yes, up to 2 drinks per day, or 4-7 drinks per week.

Yes, 3-4 drinks per day, or 8-21 drinks per week.

Yes, 5+ drinks per day or 22+ drinks per week.

Are you currently following a special diet?

No special diet

Gluten-free

Vegan

Vegetarian

Low carb/Diabetic diet

Keto

Low Sodium

Other

If other, describe your special diet.

What food allergies have you been diagnosed with?

None

Wheat

Egg

Peanut

Nuts

Soy

Sesame

Milk

Fish

Shellfish

Other

If other, what food allergies?

How many meals do you usually eat per day? (You can choose multiple if it varies)

How many snacks do you usually eat per day? (You can choose multiple if it varies)

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