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Intake form
Our coaching works through you initially filling out our intake form so that I know as much about you as possible before we sit down and set out a prescription for your daily diet. The more I know the better.
From there, we can talk about how much you should eat, when you should eat it and everything else under the sun. Our initial sit down consultation will take approximately one hour and can be scheduled after completing your intake form and payment.
Afterward, we will have a weekly sit down or online video conversation about how the process is going along with any changes we need to make to your diet so that you can meet your goals with success. I will also be available via cell phone or email anywhere along that time.
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Name
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Your answer
Height
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Your answer
Weight
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Your answer
Age
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Your answer
Gender
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Your answer
Email
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Your answer
Food recall from 3 to 7 last days? Tell me about what you ate at each meal and how much? If you know how many calories you have ate in each day, please include that.
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Your answer
Current workout routine. Please describe in detail what your workout routine looks like in terms of duration, type of activity and how many days per week?
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Your answer
Past diet history? Please list any diets you have tried in the past. This can include ketogenic, alkaline, Atkins, or many more. Also include how successful these diets were?
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Your answer
What is your daily schedule and daily activity? Please include your schedule as it pertains to work but also home and family life.
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Your answer
Current supplementation. Please list any supplements you are taking and include vitamins and minerals that you have been taking. (Melatonin, BCAAs, creatine, whey protein, and medications are all examples).
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Your answer
What do you think of when you hear, "tracking your food."
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Your answer
Food preferences and food allergies
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Your answer
How many years have you been training or working out?
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Your answer
Rate sleep
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Poor
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Awesome, sleep like a baby
Rate energy levels
dead tired
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full of energy
Clear selection
Rate sex drive
Nonexistant
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Strong sex drive
Clear selection
Current and past injuries
Your answer
Description of goals in detail. What do you hope to gain from this experience?
Your answer
Is there any other relevant information that you think I should know?
Your answer
What are your expectations from me as your nutrition coach?
Your answer
In addition, I will ask that you submit before photos so that we have a measure of your physical progress as you go along on this journey. We will want a front photo, side and back photo for this intake process.
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