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Nutrition Intake Form Questionnaire
Hello there ---Before we start working together, please fill out this required and initial questionnaire form below. I ask you to be as honest as possible and detailed when answering these questions. This form helps me set up your program for the greatest success and allows me to execute the best possible program based on your responses. Please understand that I hold the upmost expectations from every client. Both of our time is valuable, and I ensure to set my client up for success as long as you can ensure you will give it your all.

* All answers and submissions for this document are confidential and should be given with the upmost confidence*


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Full Name  *
Best Email to Contact you?  *
Gender *
Required
Age  *
Height  *
Weight  *
What do you do for a living  *
Do you have any past experience with a nutrition-based program with a coach, nutritionist or dietitian?  *
Have you attempted any weight loss/relateable programs in the past?  If so, how long ago?
Do you have any food allergies? *
If answered Yes above, please describe food allergies 
What are some of your favorite foods to go to throughout the day
*
Are there any foods you dislike ?
What is your guilty pleasure aka foods you have a hard time saying NO too?
*
How often do you consume alcohol?
 *
How Much Water do you drink on a daily basis? *
Do you drink anything else besides water? 
What is your current eating regimen? please be detailed (including amounts,  times you consume and what you consume).  Please include any Condiments as well. I have heard and read it all, there are no wrong answers- the more detailed you are, the better it helps me to build the best program for you


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Have you ever tracked/logged your food with a journal or app?  *
Do you gain weight easily?
*
Whats the heaviest you have ever weighed  *
Since you know yourself best, in terms of following a plan are you, one of the following: one that likes to be told exactly what you eat, when to eat and how much or do you prefer variety and flexibility when it comes to eating.
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In terms of health and fitness goals. Please describe what you are hoping/trying to achieve:
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What external factors have derailed you from your progress in the past:
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Are there any conditions (health or physical) your coach should be aware of?  Please be very specific.
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Who will be supporting your efforts to achieve your goals?
*
On average how much sleep do you get per night?
*

How would you rate your mental health/stress level - 1 being completely overwhelmed and 10 being completely laid back.

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Describe your current workout regimen- please detail number of days, duration, and intensity of your workouts. Also if you are currently following a split please list.
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How much cardio do you typically do on a weekly basis? and what type of cardio do you do?
*
Have you ever used PEDS (ex: SARMS, TRT, HRT, Peptides, etc).  *
If above yes, please list what you are currently cycling/taking  or what you have done in the past (please remember this is all answered in confidence). 
Are you currently on any medications? If so please list:
*

When was the last time you had bloodwork done?

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Do you suffer from any vitamin/hormone deficiencies that you are aware of?
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If Yes, please describe.
FEMALES ONLY: Are you currently pregnant?
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FEMALES ONLY:  Have you ever been pregnant? 
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FEMALES ONLY: When was your last menstrual cycle? 
Do you go for an annual physical?  *
Have you ever suffered from disordered eating? i.e. binge eating, spitting and chewing, bulimia nervosa, anorexia or another eating disorder not specified? *
Any other additional comments or concerns that I need to be aware of?
 *

CONSENT:

I am not a medical doctor.   The information I provide is based on my personal experience, Masters of Studies in nutrition & health sciences and my experience as a Certified NASM/ASFA/ACE Personal Trainer, and CNS nutritionist.  Any recommendations I may make about weight training, nutrition, supplements or lifestyle, or information provided to you in person or on this website should be discussed between you and your doctor. The information you receive in our emails, programs, services and products do not take the place of professional medical advice.


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