In order to thoroughly evaluate your health history, develop a customized plan + streamline our time together, I have curated a Client Intake Form that will  gather some of the most important details. Each question can be answered by simply typing in the box provided. If you feel as though some questions are not relevant to your health concern, feel free to skip it in order to spend more time on the more pressing health topics. Altogether, this will serve as a baseline tool from which we launch our partnership.

CONTACT INFORMATION
FULL NAME *
FULL NAME
ADDRESS *
ADDRESS
PHONE *
PHONE
STATISTICS
BIRTHDATE *
BIRTHDATE
PLEASE LIST AGES
HEALTH HISTORY
MEDICAL HISTORY
PLEASE CHECK ALL THAT APPLY.
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION OR OVER THE COUNTER MEDICATIONS? PLEASE LIST NAMES AND DOSAGE:
PLEASE LIST ANY KNOWN FOOD ALLERGIES:
PLEASE LIST ALL BRAND NAMES: VITAMINS, MINERALS, SHAKES, ENZYMES, HERBS, PROBIOTICS:
LIFESTYLE
Use this field to provide more insight into what the new you looks like. What are your specific goals? What do you plan to accomplish from working together? Is there a date you want to accomplish a specific goal? Please elaborate:
What is your work life balance? Can you give me a peek into your day to day life:
What has worked in the past? Think about a time you felt vibrant and healthy. Your best.
What has not worked in the past? What keeps you from achieving your wellness goals?
How confident are you in the kitchen? Do you do most of the cooking? Do you eat out often? Would you be willing to commit to prepping your food at home or would you prefer to invest in a service?
Please list all types of physical activity / exercise / athletic training you do, and how much / often. For example, recreational softball 3x/week.
WHAT ARE YOUR GOALS?
Check all that apply:
What is your ideal workout? Indoors? Outdoors? Group environment? Loud music? Yoga focused? What is your worst imaginable workout?
Can I thank someone for sharing my name with you?

LIABILITY FOR NUTRITION SERVICE THIS FORM IS AN IMPORTANT LEGAL DOCUMENT. IT EXPLAINS THE RISKS YOU ARE ASSUMING IN BEGINNING A HOLISTIC NUTRITION PROGRAM. IT IS CRITICAL THAT YOU READ AND UNDERSTAND IT COMPLETELY. AFTER YOU HAVE DONE SO, PLEASE PRINT YOUR NAME, EMAIL ADDRESS, AND THE DATE IN THE SPACES BELOW. NUTRITION DISCLAIMER THE NUTRITION ADVICE GIVEN BY NIKKI ELKJER IS SOLELY BASED ON THE INFORMATION PROVIDED BY THE CLIENT/INDIVIDUAL. THE NUTRITION INFORMATION GIVEN IS MEANT ONLY FOR THE CLIENT/INDIVIDUAL COMPLETING THE NUTRITION QUESTIONNAIRE FROM. IT IS THE SOLE RESPONSIBILITY OF THE CLIENT/INDIVIDUAL TO PROVIDE COMPLETE AND ACCURATE INFORMATION. NIKKI ELKJER WILL NOT BE LIABLE FOR THE EFFECTS OF A NUTRITION ASSESSMENT AND/OR ADVICE BASED ON ANY MISREPRESENTATION, MISINFORMATION, INACCURACY, OR OMITTED INFORMATION. NIKKI ELKJER PROVIDES NUTRITION COUNSELING AND IS NOT LICENSED TO PREVENT, DIAGNOSE, ALLEVIATE OR TREAT ANY MEDICAL CONDITIONS, DISEASE, PHYSICAL OR MENTAL AILMENTS OR PAIN OR INFIRMITIES. NUTRITION WAIVER AND COVENANT NOT TO SUE I (CLIENT) HAVE VOLUNTEERED TO PARTICIPATE IN A NUTRITION PROGRAM UNDER THE DIRECTION OF NIKKI ELKJER, WHICH WILL INCLUDE, BUT MAY NOT BE LIMITED TO NUTRITION AND LIFESTYLE COACHING. IN CONSIDERATION OF NIKKI ELKJER'S AGREEMENT TO ASSIST ME, I DO HERE AND FOREVER RELEASE AND DISCHARGE AND HEREBY HOLD HARMLESS NIKKI ELKJER AND HER RESPECTIVE AGENTS, HEIRS, ASSIGNS, CONTRACTORS, AND EMPLOYEES FROM ANY AND ALL CLAIMS, DEMANDS, DAMAGES, RIGHTS OF ACTION OR CAUSES OF ACTION, PRESENT OR FUTURE, ARISING OUT OF OR CONNECTED WITH MY PARTICIPATION IN ANY NUTRITION OR LIFESTYLE COACHING INCLUDING ANY INJURIES RESULTING THERE FROM. I ACKNOWLEDGE AND AGREE THAT NO WARRANTIES OR REPRESENTATIONS HAVE BEEN MADE TO ME REGARDING THE RESULTS I WILL ACHIEVE FROM THIS PROGRAM. I UNDERSTAND THAT RESULTS ARE INDIVIDUAL AND MAY VARY. NUTRITION ASSUMPTION OF RISK I RECOGNIZE THAT SPECIFIC FOODS MAY CREATE ALLERGIC AND POSSIBLE FATAL REACTIONS, MOST SPECIFICALLY, PRODUCTS CONTAINING NUTS. I HAVE THEREFORE SPECIFIED ANY FOOD ALLERGIES/SENSITIVITIES I AM AWARE OF. I AM AWARE THAT SPECIFIC FOODS MAY INTERACT WITH CERTAIN MEDICATIONS. I HAVE DISCUSSED SUCH FOOD REACTIONS AND THE SIDE AFFECTS OF ALL OF MY MEDICATIONS WITH MY DOCTOR OR PHARMACIST AND DO NOT HOLD NIKKI ELKJER RESPONSIBLE FOR FOOD AND MEDICATION REACTIONS. I ALSO UNDERSTAND THE DIET PLAN I RECEIVE WILL NOT TAKE MY MEDICATIONS INTO CONSIDERATION. IF I AM ON MEDICATION, I AM RESPONSIBLE TO CONSULT WITH MY DOCTOR BEFORE STARTING A NEW DIET PLAN. IF I AM PREGNANT OR LACTATING, HAVE HIGH CHOLESTEROL, HIGH BLOOD PRESSURE, HIGH BLOOD SUGAR, DIABETES, RENAL DISEASE, GASTRIC BYPASS SURGERY, A FAMILY HISTORY OF GOUT OR ANY OTHER MEDICAL CONDITION THAT REQUIRES SPECIAL DIETARY RESTRICTIONS, I MUST RECEIVE PERMISSION FROM MY PHYSICIAN BEFORE PARTICIPATING IN THE SPECIFIC NUTRITION PROGRAM DESIGNED FOR MY USE, OR MAY BE ADVISED TO SEEK HELP FROM ANOTHER HEALTH PROFESSIONAL. CONSENT FOR TREATMENT PAYMENT AND HEALTHCARE OPTIONS I CONSENT TO NIKKI ELKJER'S (HEREBY REFERRED TO AS THE “PRACTICE”) USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF PROVIDING TREATMENT TO ME, FOR PURPOSES RELATING TO THE PAYMENT OF SERVICES RENDERED TO ME, AND FOR THE PRACTICE’S GENERAL HEALTHCARE OPERATIONS PURPOSES. HEALTHCARE OPERATIONS PURPOSES SHALL INCLUDE, BUT ARE NOT LIMITED TO, QUALITY ASSESSMENT ACTIVITIES, CREDENTIALING, BUSINESS MANAGEMENT AND OTHER GENERAL OPERATION ACTIVITIES. ADDITIONALLY, THE PRACTICE MAY DISCLOSE MY PROTECTED HEALTH INFORMATION TO OTHER HEALTH CARE PROFESSIONALS TO PROVIDE FOR MY PROPER TREATMENT. FOR EXAMPLE, THE PRACTICE MAY NEED TO DISCUSS MY MEDICAL CONDITIONS WITH A SPECIALIST IN THE INSTANCE THAT THE PRACTICE REFERS ME TO ANOTHER HEALTH CARE PROFESSIONAL TO RECEIVE PROPER CARE. I UNDERSTAND THAT THE PRACTICE’S DIAGNOSIS OR TREATMENT OF ME MAY BE CONDITIONED UPON MY CONSENT AS EVIDENCED BY MY SIGNATURE ON THIS DOCUMENT. FOR THE PURPOSES OF THIS CONSENT, “PROTECTED HEALTH INFORMATION” MEANS ANY INFORMATION, INCLUDING MY DEMOGRAPHIC INFORMATION, CREATED OR RECEIVED BY THE PRACTICE, THAT RELATE TO MY PAST, PRESENT OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION; THE PROVISION OF HEALTH CARE TO ME; AND THAT EITHER IDENTIFIES ME OR FROM WHICH THERE IS A REASONABLE BASIS TO BELIEVE THE INFORMATION COULD BE USED TO IDENTIFY ME. I UNDERSTAND I HAVE THE RIGHT TO REQUEST A RESTRICTION ON THE USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS OF THE PRACTICE, BUT THE PRACTICE IS NOT REQUIRED TO AGREE TO THESE RESTRICTIONS. I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS CONSENT, IN WRITING, AT ANY TIME, EXCEPT TO THE EXTENT THAT THE PRACTICE HAS ACTED IN RELIANCE ON THIS CONSENT.
SIGNATURE/S/ *
SIGNATURE/S/
I UNDERSTAND THAT TYPING MY NAME AND THE DATE IN THIS BOX CONSTITUTES A LEGALLY BINDING SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF THIS AGREEMENT.
DATE *
DATE