Nutrition Intake Form
First Name
Last Name
Email
Phone Number
Date of Birth
How do you prefer me to contact you? (Check all that apply)
Email
Phone call
Text
Video chat
Emergency contact name & number
What do you want to achieve through nutritional coaching? (Check all that apply)
Lose weight/fat
Gain weight
Maintain muscle
Add muscle
Healthy aging
Improve physical fitness
Look better
Feel better
Have more energy & vitality
Improve overall health
Get control of eating habits
Get stronger
Physique competition/modeling
Improve athletic performance
Get off/decrease medications
Other (please explain below)
Other nutritional coaching objectives:
How would you like your habits, your health, your eating, and/or your body to be different?
Out of all the changes you'd like to make, which ones feel most imporant/urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body? If so, why?
Which of those things worked well for you, and why?
Which of those things didn't work well for you, and why not?
Rank your overall eating/nutrition habits on a scale of 1-10, with 1 being "Horrible" and 10 being "Awesome":
Select an option
1
2
3
4
5
6
7
8
9
10
Explain why you chose that number.
Are you regularly active in sports and/or exercise?
Yes
No
If so, approximately how many hours per week?
N/A
Fewer than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more hours
What types of sports and/or exercise do you typically do?
Approximately how many hours per week do you do other types of physical activity? (e.g. housework, walking to/from work or school, home repairs, gardening, etc)
Fewer than 5 hours
5-9 hours
10-14 hours
15-19 hours
20 or more hours
What other types of movement and/or activities do you do?
Who lives with you? (Check all that apply)
Spouse or partner
Child(ren)
Other family members
Roommates
Pets
Do you have children? If so, how many and what are their ages?
Who does most of the grocery shopping in your household?
Who does most of the cooking in your household?
Who decides on most of the menus/meal types in your household?
Rank how much the people and things around you support health, fitness, and/or behavior change on a scale of 1-10, with 1 being "Not at all" and 10 being "Completely":
Select an option
1
2
3
4
5
6
7
8
9
10
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries? If yes, tell me a little about it.
Right now, do you have any specific health concerns, such as illnesses, pains, and/or injuries? If yes, tell me a little about it.
Right now, are you taking any medications, either over-the-counter or prescription? If yes, tell me a little about it.
Rank how you feel about your schedule, time use, and overall busy-ness on a scale of 1-10, with 1 being "Panicked and insane" and 10 being "Calm and relaxed":
Select an option
1
2
3
4
5
6
7
8
9
10
How many hours per week do you spend doing any of the following: in paid employment, at school or doing schoolwork, traveling/commuting, taking care of others, volunteering, doing other unpaid work
Share anything else that you feel will give me a better understanding of you and how to help you:
Submit
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