First Name
Last Name
Email
*
Date of birth
Height
Weight
Body Fat %
What is your current activity level? Pick one that matches closet to your current level.
Low - I have a desk job and get little to no exercise per day.
Light exercise or performing a sport 1-3 times per week.
Moderate exercise or performing a sport 3-5 times per week.
Hard exercise every day or performing a sport 6-7 times per week.
Intense daily exercise (2 times a day or more) and/or difficult physical labor for 8+ hours a day.
No elements found. Consider changing the search query.
List is empty.
Typical meeting availability.
What is your primary fitness/nutrition goal? (ex: overall health, lose weight or fat, gain muscle, body composition, athletic performance, etc.)
Do you have any secondary fitness/nutrition goals?
What is the drive motivating you to accomplish your nutrition goals?
Do you think you are underweight/overweight? If yes, how many lbs would you like to lose/gain?
Do you have any health related problems (diseases such as diabetes, high blood pressure, cholesterol, etc or body stresses such as trouble sleeping, difficulty breathing, joint pain, etc.)?
How would you rate your current nutrition (Scale 0-10, 0 being terrible and 10 being perfect)?
1
2
3
4
5
6
7
8
9
10
No elements found. Consider changing the search query.
List is empty.
Where would you like your nutrition to be?
1
2
3
4
5
6
7
8
9
10
No elements found. Consider changing the search query.
List is empty.
Describe your biggest nutrition struggles:
What do you hope to get from our nutrition meeting or from nutrition coaching?
Do you currently follow a special dietary plan such as low carb, vegetarian, paleo, zone, etc? If so what? If not currently, have you ever?
Do you… Eat differently when you are alone?
Yes
No
Eat when you are upset or nervous?
Yes
No
Eat sweets or salty snacks?
Yes
No
Tend to binge eat?
Yes
No
Eat in front of the TV or computer?
Yes
No
Eat meals or snacks in the car?
Yes
No
Are you comfortable with the way you eat? Yes/No and Why?
Do you take any supplements?
How much water do you drink per day?
Do often you skip meals?
How often do you eat fast food/out at restaurants?
How would you rate your eating behaviors (such as mindfulness, eating alone, binging, snacking, etc).
How would you rate your current exercise & activity level?
How would you rate your current recovery (sleep, rest, mobility, stretching, etc)?
How would you rate your food & cooking skills (such as meal planning, meal prep, knowledge of food, experience and ability to cook many different ways)?
How would you rate your life skills (such as relationships, work performance, conflict resolution, dealing with stress, etc)
How would you rate your mindset/psychology towards health/fitness/food/self? (ex: all or nothing, food is bad/good, ability to manage/express emotions, etc)
How would you rate your current environment related to reaching your health/fitness goals? (your home, family members, friends, and workplace)
Are there any foods you cannot eat (allergic/intolerant)?
Are there any foods you absolutely refuse to eat (personal choice)?
What foods do you really like?
What do you find to be most challenging about committing to a workout or nutrition regimen?
How important are your fitness & nutrition goals? 1-10
1
2
3
4
5
6
7
8
9
10
No elements found. Consider changing the search query.
List is empty.
What will the benefits of reaching your goals be?
What will you have to sacrifice to get there?
How confident are you that you can change your nutrition and exercise habits?
Please add any additional info you feel may be relevant to understanding your nutritional health:
Submit