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Nikki Martin
About
Longevity
Private Chef
The Well Diary
Contact
Nikki Martin
About
Longevity
Private Chef
The Well Diary
Contact
About
Longevity
Private Chef
The Well Diary
Contact
nikki martin, cn-p · longevity youprint

Client Intake Form

Take your time with this — the more you share, the more precisely we can build your protocol.

This form is for wellness and nutrition coaching purposes only. It does not constitute medical advice, diagnosis, or treatment. Please consult your physician before making changes to your health regimen.

the basics

about you

health history

your medical background

current diagnosed conditions (check all that apply)
include anything relevant — dates, context, outcomes
include dosages if known
relevant conditions in immediate family members
diet & nutrition

how you eat

current dietary approach (check all that apply)
walk us through breakfast, lunch, dinner, snacks — include timing and roughly how meals are prepared
history of disordered eating or difficult relationship with food?
food sensitivities & allergies

safety first

confirmed food allergies (IgE-mediated)
suspected or known sensitivities / intolerances
symptoms, timing, foods that trigger them
have you had a food sensitivity test?
functional testing history

tests you've done

check any tests you've completed — add date and key findings where you remember them.

completed tests (check all that apply)
e.g. "DUTCH showed low progesterone, high cortisol — done March 2024"
do you have test results you can share?
lifestyle & sleep

your daily rhythms

current exercise habits (check all that apply)
very lowvery high
very lowexcellent
symptoms & concerns

what's going on right now

current symptoms (check all that apply)
when did it begin, what makes it better or worse, what you've already tried
goals & intentions

where you want to go

primary wellness goals (select up to 3)
describe how you want to feel, function, and live
have you worked with a nutritionist or functional medicine practitioner before?
disclaimer & consent

before you send

not medical advice

Nikki Martin is a Wellness Chef and Certified Nutrition Practitioner (CN-P). All services, content, and recommendations are for educational and wellness-support purposes only — not medical advice, diagnosis, or treatment. Nothing shared here replaces the care of a licensed physician or healthcare professional.

Functional lab testing and DNA analysis are interpreted from a nutrition and wellness perspective only, not as clinical diagnosis. Always consult your physician before making significant changes to your diet, supplements, or exercise routine — especially if you have an existing health condition, are pregnant or nursing, or take prescription medications.

Individual results vary and are not guaranteed. Your information will be kept strictly confidential and will not be shared with third parties without your explicit consent, except as required by law.

I have read and understood the above. I confirm my information is accurate, I am voluntarily participating, and I understand this is a wellness coaching program — not a substitute for medical care. *
nikki martin, cn-p · nikkimartin.com · eat well. be well. live well.

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Who wants to “diet” anyway ? Food is medicine. Food is fuel. Every meal you eat is an opportunity to either feed or fight dis/ease. Armour your body with the fuel it needs for the long haul. Simple formula for success:: Aim for 25-3
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a diary on all the things on being

well + aging well + thriving

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Nikki Martin

longevity expert, wellness chef, and certified nutrition practitioner. here you will find my musings on living a full, vibrant and healthy life.

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