Name
Email
Age
Height
Weight
Occupation
What are your top 3 health complaints or concerns?
If I could wave my miracle wand, what would you LOVE to accomplish by the end of our work together?
What have you tried in the past to reach your goals? Meal plans
Macro tracking
GLPs
Specific diets i.e. keto
Are you open to changing your eating habits, tracking nutrition and consistent training if its required for your goals? Yes
No
Current diet description- Outline a typical day of meals and snacks.
Which foods do you really like? Protein sources, carb sources, fat sources, fruits and vegetables or other?
What types of sauces, spreads, cooking oils or condiments do you typically use preparing your meals?
Which foods do you dislike or are allergic to?
How many times did you eat per day?
Did you snack between meals or feel hungry between meals?
How often do you eat at restaurants or order in and what do you typically order?
Where do you grocery shop?
Average daily water intake?
What other forms of liquid do you drink? Coffee, tea, juice, pop
Do you currently do any structured cardio ( including walking)? If so, which types and for how long?
Do you currently track your steps using a smart watch, pedometer, Oura Ring or similar device?
Do you currently do any strength training? If so , how many days a week?
For strength training, would you exercise at home or in a gym? If at home, please list equipment you have available.
How many days a week can you commit to strength training? i.e 3,4 or 5 days
Do you play any sports? If so, which ones?
Average amount of sleep per night ( in hours)?
What time do you normally go to bed and normally wake up?
What are your primary stressors in your life?
Do you take any medication or supplements? If so , please list.
Do you drink alcohol or smoke cigarettes or other?
Do you have a history of any of the following? Please select all that apply. disordered eating
high cholesterol
Diabetes
Hormone imbalances
heart disease
High blood pressure
Vitamin deficiency
None of the above
Other
Anything else you would like to include that wasn't already noted ?
SUBMIT YOUR ANSWERS
