Private Coaching with Ti – Intake Form

Initial intake form for private coaching with Ti Caudron, PhD. Please note: Ti Caudron, PhD is a nutrition and weight loss coach and not a medical doctor. Please relay all medically related questions to your healthcare practitioner.

Step 1 of 3

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  • What is the name and type of practitioner? When did you see them? What were the results? Why did you continue or discontinue? Please describe.
  • For example, are you willing to keep a daily food journal?
  • Please name which programs or eating styles you have tried and the results you have achieved. For example: lost weight, medical changes, sleep, energy, mental clarity, cravings, or other.
  • What are you able to do more of / who are you able to be? - Example would be; more patient, more clear, more energetic, better sleep, fewer cravings, etc.
  • General Information

  • Please use the + button to add rows as needed for each additional child. Type N/A into the first box if not applicable.
    GenderAgeYes, Lives at HomeNo, Does Not Live at Home 
    Add a new row
  • Please list your known Medical Conditions (e.g., high blood pressure, diabetes, elevated blood sugar, cholesterol, high LDL, low HDL, elevated liver enzymes, cancer, food allergies or sensitivities etc.) and the year they started. Use the + button to add additional rows as needed — This information will be kept confidential!
    Add a new row
  • Please list Medications you are taking, the dose, how often and what you are taking them for. Please use the + button to add rows as needed for each additional Medication. Type N/A into the first box if not applicable.
    MedicationDoseFrequencyReason 
    Add a new row
  • Please list what Supplements you are taking, the amounts, how often and what you are taking them for. Please use the + button to add rows as needed for each additional Supplement. Type N/A into the first box if not applicable.
    SupplementDoseFrequencyReason 
    Add a new row
  • Describe how you normally eat. Check the boxes for all that apply.