NUTRITIONAL INTAKE FORM Name * First Name Last Name Email * Phone (###) ### #### Age? Have you ever had any surgeries? (If YES, please explain.) Are you taking any supplements? (Please list.) Are you currently taking any medication? (If YES, please explain.) Date of last physical Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If YES, please explain.) What is your current occupation? Does your occupation cause you mental stress? Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) Describe your nightly sleep, including how many hours Do you often feel fatigued or have low energy levels, even after getting adequate rest? Have you noticed changes in your mood, such as increased irritability, anxiety, or depression, that seem to be unrelated to external factors? Any additional Message? How did you hear of us? Save 10% on Thorne nutritional products? Coach Lee is an affiliate with Thorne. When it comes to supplements, recipe is key and Coach Lee believes that Thorne is one of the finest supplement companies in the world. https://www.thorne.com/ Yes No Thank you!
