Client Intake Form
for Integrated Wellness Programs
Client Information
First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Zip/Postal Code
Emergency Contact
First Name
Last Name
Phone Number
Relationship
Health and Wellness History
Do you have any pre-existing medical conditions or chronic illnesses?
If yes, please specify.
Are you currently under the care of a physician or healthcare provider?
If yes, please provide details.
Are you currently taking any medications?
If yes, please list.
Do you have any allergies (e.g., food, medications, environmental)?
If yes, please specify.
Have you ever been diagnosed with a mental health condition (e.g., anxiety, depression)?
If yes, please specify.
Do you have any physical limitations or injuries that may affect your participation in wellness programs?
If yes, please describe.
What is your primary goal for participating in a wellness program? (Check all that apply)
Stress reduction
Weight management
Improved fitness
Better nutrition
Mental clarity
Emotional balance
Chronic pain management
Other:
Lifestyle and Habits
How would you describe your current activity level?
Sedentary
Lightly active
Moderately active
Very active
How many hours of sleep do you typically get per night?
Less than 5
5-6
7-8
More than 8
Do you smoke or use tobacco products?
How often do you consume alcohol?
Never
Occasionally
Regularly
Frequently
How often do you consume alcohol?
Balanced
Vegetarian
Vegan
Low-carb
High-protein
Other:
What is your current stress level?
Low
Moderate
High
Very High
Wellness Program Options
Please review the following program options and indicate your interest level (1 = Not Interested, 5 = Very Interested):
Program | Description | Interest Level (1-5) | ||
|---|---|---|---|---|
A | B | C | ||
1 | Individual Coaching | One-on-one sessions tailored to your specific wellness goals. | ||
2 | Group Fitness Classes | Group sessions focusing on yoga, Pilates, HIIT, or strength training. | ||
3 | Nutrition Counseling | Personalized meal planning and dietary guidance. | ||
4 | Mindfulness & Meditation | Guided meditation, breathing exercises, and stress management techniques. | ||
5 | Weight Management | Programs designed to support healthy weight loss or maintenance. | ||
6 | Chronic Pain Management | Techniques and exercises to alleviate pain and improve mobility. | ||
7 | Mental Health Support | Counseling or workshops for anxiety, depression, and emotional well-being. | ||
8 | Corporate Wellness | Workplace programs to improve employee health and productivity. | ||
9 | Holistic Therapies | Acupuncture, massage therapy, or energy healing sessions. | ||
10 | Outdoor Adventure Programs | Hiking, nature retreats, or team-building activities in natural settings. |
Program Suitability Questions
Do you prefer individual or group settings for wellness activities?
Individual
Group
No preference
What time of day are you most available for wellness activities?
Morning
Afternoon
Evening
Weekend
How many hours per week are you willing to dedicate to a wellness program?
1-2 hours
3-5 hours
6-10 hours
More than 10 hours
Are there any specific activities or therapies you would like to avoid?
If yes, please specify.
Do you have any religious, cultural, or personal preferences that may affect your participation?
If yes, please explain.
What motivates you to participate in a wellness program?
Health improvement
Social interaction
Professional recommendation
Personal curiosity
Other:
How do you prefer to receive program updates and communication?
Phone
Text
In-person
Other:
Additional Comments or Concerns
Is there anything else you would like us to know about your health, lifestyle, or goals?
Consent and Agreement
I certify that the information provided in this form is accurate to the best of my knowledge.
I understand that this information will be used to design a personalized wellness program and ensure my safety during participation.
Client Signature
Client Intake Form Insights
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
Below is a detailed breakdown of Client Intake Form, explaining the purpose of each section, the type of information gathered, and how it contributes to designing a personalized wellness program for the client.
1. Client Information
Purpose:
To collect basic demographic and contact details for identification, communication, and emergency purposes.
Key Insights:
- Full Name and Date of Birth: Helps in personalizing the program and maintaining accurate records.
- Contact Information: Ensures the provider can reach the client for scheduling, updates, or emergencies.
- Emergency Contact: Critical for safety, especially in group or physical activity-based programs.
2. Health and Wellness History
Purpose:
To assess the client’s current health status, identify potential risks, and ensure the wellness program is safe and appropriate.
Key Insights:
- Pre-existing Medical Conditions: Helps tailor programs to avoid exacerbating health issues (e.g., avoiding high-intensity workouts for someone with heart conditions).
- Medications: Certain medications may affect energy levels, weight, or mood, which can influence program design.
- Allergies: Essential for nutrition programs or therapies involving supplements, herbs, or environmental exposures.
- Mental Health Conditions: Allows for the inclusion of mental health support or mindfulness practices if needed.
- Physical Limitations: Ensures exercises or activities are modified to accommodate the client’s abilities.
- Primary Goals: Identifies the client’s motivations, ensuring the program aligns with their desired outcomes (e.g., stress reduction, weight management).
3. Lifestyle and Habits
Purpose:
To understand the client’s daily routines, behaviors, and habits that may impact their wellness journey.
Key Insights:
- Activity Level: Helps determine the starting point for fitness programs (e.g., beginner vs. advanced).
- Sleep Patterns: Poor sleep can affect stress, weight, and overall health, indicating a need for sleep hygiene education.
- Smoking and Alcohol Use: Identifies areas for lifestyle modification and potential barriers to wellness.
- Diet: Provides a baseline for nutrition counseling and meal planning.
- Stress Level: High stress may indicate a need for mindfulness, meditation, or stress management programs.
4. Wellness Program Options
Purpose:
To gauge the client’s interest in various wellness programs and identify which ones resonate most with their goals and preferences.
Key Insights:
- Interest Level (1-5): Helps prioritize programs that the client is most excited about, increasing engagement and adherence.
- Program Descriptions: Educates the client about available options, ensuring they make informed choices.
- Customization: Allows the provider to combine multiple programs (e.g., nutrition counseling + fitness classes) for a holistic approach.
5. Program Suitability Questions
Purpose:
To gather preferences and logistical information that ensure the program fits seamlessly into the client’s life.
Key Insights:
- Individual vs. Group Settings: Some clients thrive in social settings, while others prefer one-on-one attention.
- Availability: Ensures scheduling aligns with the client’s routine, reducing dropout rates.
- Time Commitment: Helps set realistic expectations and design a program that fits their lifestyle.
- Activities to Avoid: Respects the client’s boundaries and ensures comfort (e.g., avoiding yoga if they dislike stretching).
- Religious/Cultural Preferences: Ensures the program is inclusive and respectful of their beliefs.
- Motivations: Understanding what drives the client (e.g., health improvement, social interaction) helps tailor the program to keep them engaged.
- Communication Preferences: Ensures the client receives updates in their preferred format, improving satisfaction.
6. Additional Comments or Concerns
Purpose:
To provide the client with an opportunity to share any additional information that may not have been covered in the form.
Key Insights:
- Unspoken Needs: Clients may reveal unique challenges, goals, or preferences that require special attention.
- Trust Building: Encourages open communication, fostering a stronger client-provider relationship.
7. Consent and Agreement
Purpose:
To formalize the client’s acknowledgment of the information provided and their commitment to the wellness program.
Key Insights:
- Legal Protection: Ensures the client understands the purpose of the intake form and agrees to its use.
- Client Accountability: Encourages the client to take ownership of their wellness journey.
How This Form Informs Program Design
- Personalization: The form provides a comprehensive overview of the client’s health, lifestyle, and preferences, enabling the creation of a tailored wellness plan.
- Safety: Identifies potential risks (e.g., medical conditions, allergies) to ensure the program is safe and appropriate.
- Engagement: By understanding the client’s motivations and interests, the provider can design a program that keeps them motivated and committed.
- Logistical Fit: Ensures the program aligns with the client’s schedule, preferences, and comfort level.
- Holistic Approach: Combines physical, mental, and emotional wellness components for a well-rounded experience.
Example Use Case
A client completes the form and indicates:
- High stress levels and poor sleep.
- Interest in mindfulness, meditation, and nutrition counseling.
- A preference for evening sessions and group settings.
Based on this information, the provider might recommend:
- A weekly group mindfulness and meditation class in the evenings.
- Personalized nutrition counseling to address stress-related eating habits.
- Sleep hygiene education as part of the program.
This approach ensures the program is both effective and enjoyable for the client, increasing the likelihood of long-term success.
This detailed intake form is a powerful tool for creating a client-centered wellness program that addresses their unique needs, preferences, and goals.
To configure an element, select it on the form.