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Evoke Resolutions Programs
Who What Why
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Evoke Resolutions Programs
Who What Why
Evoke
Contact
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New Client Intake Form
Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
What's your objective? (Get healthier, decrease size, decrease body fat %, improve athletic performance, feel better, etc.)
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How much flat water (ounces) do you drink per day on average?
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Is there a specific health condition you are addressing? (high blood pressure, high cholesterol, diabetes, pregnancy, overweight, etc.)
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What do you typically eat for breakfast? Include amount of each item.
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What do you typically eat for lunch? Include amount of each item.
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What do you typically eat for dinner? Include amount of each item.
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What do you typically eat for snacks throughout the day? Include amount of each item.
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On average, how many alcoholic drinks do you drink per day?
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On average, how many caffeinated beverages do you drink per day?
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What diet change will you be making/has yoru dr recommended (decrease amount, decrease/eliminate specific items (please list), pre-determined diet (Whole 30, etc.)?
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What do you currently do for exercise?
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How many days per week do you do each type of exercise?
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For how long do you do each exercise?
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What would you like to be doing for exercise/what has your dr. recommended you do for exercise? (amount/frequency/type)
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Thank you!
Evoke Resolutions | Intake Form
New Client Intake
