Mackeyfit Intake Form for New Clients

Holistic Health Integration Profile and Consultation

Consultation counts as 1st session in any package.

Name__________________________ Home Phone: _________ Cell: __________

Address: ________________________________ Email: ________________________________

Preferred mode of communication for appointments and scheduling: email / phone / text message

Birthday: (m/d/y) _____________________ Exact time and place if known : _______________________


Outline of topics covered:

I. General Health and Fitness Questions
II. Health History
III. Athletic and Fitness Background &Experience
IV. Nutrition and Supplementation
V. Environmental Factors and Conditions
VI. Energetic Systems Assessment, including Aura and Chakras, Feelings, Emotions, Consciousness
VII. Numerology
VIII. Astrological Profile
IX. Goals
X. Fitness Personality
XI. Feedback, Cuing, Individual Notes:
XII. Notes from general dialogue
XIII. Individualized & Suggested Reading and Materials List.

Please complete sections 1-10. 7 and 8 and 11-13 will be covered in person.


I General Health and Fitness Questions:

A. How do you currently feel? _________________________________________________
____________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. What does “healthy”, look and feel like to you? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. What would it take for you to look and feel like you want to? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. Health History
A. Family and Genetic health and predispositions? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Beliefs about health and patterns? ___________________________________________________________________________________________________________________________________________________________________________________________________
C. Experienced any serious illnesses? ___________________________________________________________________________________________________________________________________________________________________________________________________
D. Overall attitude and general outlook on life? ___________________________________________________________________________________________________________________________________________________________________________________________________
E. Pain in any areas please list ___________________________________________________________________________________________________________________________________________________________________________________________________
F. Taking any medications? For? __________________________________________________________________________________________________________________________________________________________________________________________________

Other Notes:


III. Athletic and Fitness Background and Experience

A. What sports and activities have you participated in? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Self efficacy within those sports and activities?__________________________________________________________________________________________________________________________

C. Duration, years played, time frame, skill level?______________________________________________________________________________________________________________________________________________________________________________________________
D. Exercise experience – free weights, machines, yoga, cardio? Other modes of exercise?_____________________________________________________________________________________________________________________________________________________________________________________________
E. Which do you MOST enjoy?______________________________________________________________________________________________________________________________________________________________________________________________
F. What activities make you feel more energized?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. What activities make you feel relatively less energized or depleted?___________________________________________________________________________________________________________________________________________________________________________________________
H. Which make you feel strongest and most fit?_______________________________________________________________________________________________________________________________
I. Preferred exercise intensity and workout length?_____________________________________________________________________________________________________________________________________________________________________________________________
J. What kind of program do you currently follow if any….how is it structured?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
K. Have you had a trainer before? What was your experience? Likes/dislikes? Preferences?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:

IV. Nutrition and Supplements
A. Tell me everything that goes into your body….___________________________________________________________________________________________________________________________Typical Breakfast:___________________________________________________________________________________________________________________________________________________________________________________________Lunch:_____________________________________________________________________________________________________________________________________________________________________________________________Dinner:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Snacks_____________________________________________________________________________________________________________________________________________________________________________________________


B. Eating habits; times of day, speed, portion sizes, food combinations?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


C. Any dairy? What kinds/how much? __________________________________________________________________________________________________________________________________________________________________________________________________
D. What kinds of meat? How often and how much?______________________________________________________________________________________________________________________________________________________________________________________________
E. How much water do you drink? From what source?__________________________________________________________
F. Past habits, use of vitamins, minerals, supplements?_______________________________________________________________________________________________________________________
G. Any known vitamin/mineral deficiencies?________________________________________________________________________________________________________________________
H. Any emotional eating?____________________________________________________________________________________________________________________________
I. Digestion and assimilation ok?_________________________________________
J. Metabolic functioning? Rate?_____________________
K. Food allergies?_______________________________________________________
L. Blood Type: ________


Notes:

V. Environmental Factors and Conditions
A. Homeostatic and balanced living conditions?_________________________________________________________________________________________________________________________
B. Do you use air/water purifiers?________________________________________________
C. Hours of rest?_____________________________________
D. Feelings of balance or restlessness at home and work?
E. Stress? Please describe in detail your major stessors, if any, and how you mange them. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
F. Relative point/time in life journey? Transition?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
G. Would you be interested in having a Astrology/Numerology/Archetype consultation to get a clear view on your life path and position? __________________________________________________________________________________________________________________________________


VI. Energetic Systems Assessment, Including Chakras, Emotions, Sensitivities (if answering these questions over email, I will go into more depth in person, with this section.)

A. 1st Chakra -- are there any cultural, societal, familial, tribal beliefs that you notice effect you daily, positively or negatively? Are you grounded? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


B. 2nd Chakra -- What is your relationship to money, power, uniting with others?_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


C. 3rd Chakra -- How do you feel about yourself? Honest with yourself? Trust yourself? Feel courageous? Confident? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


D. 4th chakra --- lessons of forgiveness, love, emotions….how open is your heart center? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


E. 5th chakra --- richest power comes from actions motivated by personal will that trusts Divine Authority. Do you make wise and empowering choices for yourself and others? Are your heart and mind congruent and communicating or blocked and not working together? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


F. 6th chakra -- what is the quality of your symbolic perspective? Do you see things clearly? Are you able to detach and see objectively the symbolic reasons for why things happen, and put them into proper perspective that empowers, rather than dis-empowers you?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


G. 7th chakra -- faith, spirituality, devotion, values, bigger picture, grace bank account. What is your relationship to the divine? Can you follow inner guidance when it is bestowed upon you?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


VII. Numerology : ________________________ (will cover in person)


VIII. Astrological Profile :________________________________________ (will cover in person)

IX. Goals
A. Primary ____________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Short Term (1 to 3 months) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
C. Mid range: (3 to 12 months) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
D. Long Range: (1 year and beyond)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Means to achieve these goals: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Process goals (not just outcome goals!): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


X. Fitness Personality ______________________________________________
A. Prefer to workout individually? With a partner? In larger group settings? Classes?
B. Current level of motivation on a scale of 1 to 10? _____________________________
C. What is motivating you? Intrinsically or extrinsically motivated? ( By something inside/outside of yourself?) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


XI. Feedback/Cueing/Individual Notes


XII. Notes from General Dialogue

XIII. Individualized and Selected Reading Materials Recommended