About this template
Streamline client intake for your wellness practice with this Health and Wellbeing Consultation Google Form template. Designed for holistic practitioners, coaches, physical therapists, and wellness consultants, this form gathers essential background information before a first appointment. It covers critical areas including personal details, lifestyle habits, exercise routines, family health history, and current medications.
Collecting this data in advance allows practitioners to review client needs thoroughly, leading to more personalized and effective consultation sessions. With Doc2Form, you can instantly turn this template into a live Google Form, making it simple to share securely with new clients via email or your website.
Whether you run a private wellness clinic, a nutrition coaching service, or a holistic health practice, using a standardized intake form ensures you never miss vital health details while saving valuable time during initial sessions.
Key features
- Comprehensive health and lifestyle history collection
- Pre-consultation data gathering for better session prep
- Fully customizable questions to match your practice
- Optimized for desktop and mobile client responses
- Instant setup as a ready-to-use Google Form
Use cases
- Initial intake for new nutrition or wellness coaching clients
- Pre-appointment screening for holistic health practitioners
- Physical therapy and personal training initial health assessments
- Mental health and wellness counseling intake questionnaires
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Birth Date (Date)Select your date of birth.
- Mobile Number (Short answer)Enter the best phone number to reach you.
- Email Address (Short answer)Enter your primary email for appointment updates.
- Gender (Dropdown)Select your gender identity.
- Occupation (Short answer)What is your current occupation or daily work environment?
- Main Health Challenges (Paragraph)Describe your primary health concerns or goals for this consultation.
- Symptom Trigger Factors (Paragraph)What factors (e.g., stress, certain foods, lack of sleep) seem to trigger or worsen your symptoms?
- Health History (Paragraph)Briefly describe any past major illnesses, surgeries, or chronic conditions.
- Hospitalisation Status (Multiple choice)Have you ever been hospitalized?
- Hospitalisation Details (Paragraph)If yes, please provide dates and reasons for hospitalisation.
- Family Health History (Paragraph)Note any significant health conditions that run in your immediate family.
- Medication Status (Multiple choice)Are you currently taking any prescription medications, vitamins, or supplements?
- Medication Details (Paragraph)If yes, please list the names and dosages of medications or supplements.
- Exercise Frequency (Dropdown)How often do you engage in physical exercise or activity?
- Lifestyle Habits (Paragraph)Describe your typical daily habits regarding sleep, diet, hydration, and stress levels.
- Plan Readiness Status (Linear scale)How ready are you to make lifestyle changes to improve your health?
- Other Comments or Notes (Paragraph)Is there anything else you would like your practitioner to know before your session?
FAQ
How do I share this form with my clients?
Once generated in Google Forms, you can share the form link via email, text message, or embed it directly on your practice website.
Can I add or remove questions?
Yes, because the template lives in your Google Drive, you have full control to edit, add, or remove any questions to suit your specific practice.
Is this form template free to use?
Yes, this template is completely free to convert and use via Google Forms.
How do I access the client responses?
All submissions are automatically saved in a linked Google Sheet, allowing you to review responses and track client intake data securely.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.