Intake Form – Step Up To The Plate Nutrition Logo
  • New Client Intake Form

    The first step on the path to wellness!
  • This form is 7 pages long, and should take approximately 15-20 minutes to fill out.

    Use your home computer to fill out this intake form. It's best to not to use a public computer, such as at the library.

    Please don't worry if you are unable to recall exact dates or names of medications you have taken. We will be discussing this information and I will be able to get additional clarity through our consultation conversation.

  • 1: Your Contact Info

    Let's start with the basics. Who are you, and how can we get in touch?
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  • 2: Your Personal Info

    Now let's get a little personal – tell me a bit more about yourself.
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  • 3: Health Goals & History

    Let's talk about how you're feeling now, and how you'd like to be feeling in the future.
  • Family Health History

    Please note any significant health issues for the following family members.
  • Dental Health

  • 4: Medications & Nutritional Intake

    Let's talk about what you're currently consuming.
  • Daily Consumption

    Please indicate your daily consumption of the following items.
  • 5: Habits & Patterns

    Let's discuss some of the things you do regularly.
  • Bowel Movements & Urination


  • Sleeping Habits

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  • Menstrual Cycle & Pregnancy

  • Prostate Health

  • 6: Work & Home Life

    Let's take a look at what you do, what you've done, and how you handle stress.
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  • Stress & Hobbies

  • Do you use any of these items?

  • 7: Agreement & Consent

    You're nearly done!
  • Terms & Conditions

    I, {name}, understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matter intended for general well-being, and are not meant for the purposes of medical diagnosis, treatment, or prescribing of medicine for any disease.

    As the client I take full responsibility for my health, healing, and progress on my nutrition plan. Any herbal formula suggested will only be used with the supervision of a doctor. The acknowledgement of this statement is being signed with intention to achieve optimal health and voluntarily. This information is proved for a nutritional assessment and is not diagnostic.

    I understand that the information I am provided will be used in accordance with the Canadian Privacy Act and will not be shared with anyone. Information may be shared at my request with my physician or healthcare provides that I deem appropriate.

    Payments for consultations are paid in full at the time of the initial consult and can be made via cash or e-Transfer.

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