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Nutrition Intake Form
Please fill out the following form.
First name
Last name
Date of birth
Month
Month
Day
Year
Email
*
Phone Number
*
Preferred Method of Communication?
*
Phone Call
Text Message
Weight
*
Height
*
Occupation
Do you have any current medical conditions (Check any that apply)
*
High Blood Pressure
Diabetes
High Cholesterol
Thyroid Disorder
Digestive Issues (e.g. Crohn's Disease, IBS)
Heart Disease
Autoimmune Disorders
Other
Are you currently taking any medications?
*
No
Yes
Do you have any dietary restrictions or allergies?
No
Yes
Have you experienced significant weight fluctuations in past
*
No
Yes
Do you have a family history of weight-related health issues or conditions?
*
No
Yes
Are you pregnant or trying to become pregnant?
*
Yes
No
Describe a typical day's meal and snacks: (Breakfast/Lunch/Dinner/Snacks/Beverages: Coffee, tea, soda, alcohol, etc.)
*
Is there anything else you'd like us to know to help create your workout plan?
*
How many times a week do you eat out?
*
Do you follow specific dietary plans?
*
Vegetarian
Vegan
Paleo
Keto
Mediterranean
Other
How often do you consume sugar?
*
Daily
Weekly
Occasionally
Never
How often do you consume processed foods?
Daily
Weekly
Occasionally
Never
How often do you consume fast foods?
*
Daily
Weekly
Occasionally
Never
How often do you consume alcohol?
*
Daily
Weekly
Occasionally
Never
How often do you consume sweets/deserts?
*
Daily
Weekly
Occasionally
Never
How often do you consume gluten?
*
Daily
Weekly
Occasionally
Never
Are there any foods you dislike or avoid?
*
Do you feel like your eating habits are healthy
*
Yes
No
Do you exercise regularly
*
Yes
No
If "YES" to the question above, what types of physical activity do you engage in?
*
Cardio (running, cycling, swimming)
Strength Training
Yoga/Pilates
Group Classes
Sports
Other
How many days a week do you exercise
*
How long are the duration of your workouts in minutes?
*
Do you have any physical limitations or injuries that affect your ability to exercise
No
Yes
How would you describe your stress levels?
*
Low
Moderate
High
How many hours of sleep do you get per night on average?
*
Do you smoke or use tobacco products?
*
No
Yes
How often do you consume alcohol?
*
Often
Occasionally
Rarely
Never
What are your primary goals for seeking nutrition and weight loss guidance?
*
Lose Weight
Gain Muscle
Improve Health
Increase Energy
Other
Why is this goal important to you?
*
On a scale of 1-10, how motivated are you to make lifestyle changes?
*
Have you tried to lose weight before?
*
No
Yes
What do you see as your obstacles to reaching your weight loss goals?
*
What is your ideal timeline for achieving your goal weight?
*
DO you experience emotional or stress related eating?
*
No
Yes
Do you feel shame or guilt after eating?
*
No
Yes
Do you track your food intake?
*
No
Yes
How confident do you feel in your ability to stick to a nutrition plan long term?
*
No
Yes
How confident do you feel in your ability to stick to a nutrition plan long term?
*
No
Yes
How confident do you feel in your ability to stick to a nutrition plan long term?
*
I there anything else you would like to share about your relationship with food or weight loss challenges?
*
Are you currently working with any other health professionals (e.g., personal trainer, therapist)?
*
No
Yes
What does success look like for you in terms of your health and wellness journey?
*
Are you interested in meal planning, recipes, or guidance on specific diets?
*
Submit
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