Nutrition Consultation Intake Form
Once you complete and submit the form, you will receive an invoice via email for the initial consultation fee of $50 which includes a detailed review of your history and current eating habits/health. The payment link will be included. Upon receipt of payment you will receive a follow up call/email to schedule your consult which will include additional options going forward.

Please complete this form with as much detail and as honestly as possible. I assure you, I've heard it all and the more light you shed on your history and current state, the better. Your information will be keep confidential.

What's your name? *
First AND Last
Your answer
Please provide your email, phone # and best time of day to contact you. *
Your answer
What is your biggest struggle? *
Your answer
Do you have an issue with any of the following? *
Required
What is your age, height and current weight? *
I will need your lean body mass and body fat percentage. We will discuss these options later on.
Your answer
How often do you exercise and what type of job do you have? *
i.e. sedentary, moderately active, physically demanding
Your answer
What have you tried in the past that worked or didn't work? Please be specific and detailed. *
Ex: Weight Watchers, belong to a gym, group fitness classes, running, had a personal trainer, etc
Your answer
What are you trying to accomplish? Why? *
Your answer
What makes this time different than previous attempts? What's your motivation? *
Your answer
How often do you eat out & where? *
Your answer
How much water do you consume per day? *
Your answer
Describe in detail what a typical day of meals looks like for you. *
Your answer
What's your favorite food? *
Your answer
Do you have any dietary restrictions that need to be considered? *
Are you needing a full meal plan or basic guidance? *
Your answer
Are you on any medications? *
Anything else of importance you feel needs addressing? *
Your answer
Please list any medical and/or family history of illnesses, medications, etc that may be of importance. *
i.e.-family history of high blood pressure, high cholesterol, etc
Your answer
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