Nutrition Assessment Intake Form

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Please fill the following Intake form out in detail for your assessment Be as accurate and thorough with your responses as you can be. This will ensure the best results from your plan.

Thank you!

What is Your First and Last Name? *

What is an email I can reach you on? *

I will use this email to send over relevant info about your assessment- and get in touch to go over your results with you. Nothing promotional will be emailed to you!

What is your current weight? (Lbs, or Kgs) *

If you can weight yourself before so we have an updated, and accurate weight to create your plan.

What is your "Goal Weight"? *

If you're not sure, feel free to write "Not Sure".

What is your height? *

What is your age? *

How many times a week do you consistently exercise? (This means purposeful exercise sessions, not just daily activity) *

Be as honest as possible. It is totally okay if you do not exercise right now.

No purposeful exercise.

1-2 times a week

2-4 times a week

4-7 times a week

Other:

If you participate in weekly purposeful exercise, briefly explain what that looks like below.

For example: "I run 2 miles twice a week at a moderate jog, and strength train once a week for 1 hour."

How would you describe your daily movement, outside of purposeful exercise? *

Very Light (most people fit in this category): Desk job, sitting most of the day.

Light (a mix of sitting and standing): An example would be a teacher.

Moderate (continuous gentle to moderate activity throughout the day): Retail employees, restaurant servers, etc.

Heavy (strenuous movement throughout the day): Construction worker.

Do you have any specific dietary preferences/restrictions? *

(vegan, gluten free, dairy free, etc)

Do you have any medical conditions?

What are your current health and fitness goals? *

AKA what do you want to achieve from doing this session together?

Why does this goal matter to you? *

Why are you interested in working on this goal at this time in your life? *

When you try to lose weight, what do you feel holds you back from being successful? *

This can be either with nutrition, exercise, or mindset. Just list out the obstacles that make it hard to stick to a weight loss/ nutrition plan.

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