Foundry Nutrition Program Intake Form v2
Help us learn more about your nutrition habits. We're in this together, starting today. This form should take about 10 minutes. Think of it as a part of your first nutrition coaching session – and an investment in yourself. We take your privacy very seriously. Everything you tell us is confidential.
Email address *
Mobile phone number *
Your answer
Best Time to Call *
Link to your Facebook profile
If you sign-up for the program we will add you to our private Foundry Nutrition Program Facebook group. A core part of participating in this Foundry Nutrition Program is sharing photos of your meals and or sharing short posts in our private Nutrition Program Facebook Group about your habits 3x/week for the next 4 weeks.
Your answer
What are your goals?
Check all that apply.
If you had to choose between the following 4 goals, which one is most important to you?
Your current weight is roughly...
Your answer
What's your biggest nutritional challenge?
Check all that apply.
Which high protein foods do you like?
Here are some foods that are high in protein. Please check off all that you like and will eat.
Which common vegetables do you like?
Here are some common vegetables. Please check off all that you like and will eat.
Which foods that are higher in carbohydrates (sugars and starches) do you like?
Here are some foods that are higher in carbohydrates (sugars and starches). Please check off all that you like and will eat.
Which foods that have healthy fats do you like?
Here are some foods that have healthy fats. Please check off all that you like and will eat.
If you have food sensitivities or dietary restrictions, list them here.
Your answer
If you are using any nutritional supplements, list them here.
Your answer
How often do you drink alcohol?
On an average day, how many glasses of water do you drink?
On an average day, how many of your meals include at least a palm-sized portion of protein (like meat, fish, dairy, eggs, or other protein-dense plant foods)?
On an average day, how many of your meals include at least one serving of colorful fruit or vegetables?
How many hours a week do you do some form of exercise training?
What is your typical stress level at home?
Choose the answer that best applies.
For all your lifestyle-related stressors, how well do you cope with stress?
Choose the answer that best applies.
Anything else you'd like to share?
Your answer
Integrity statement (please read and confirm) *
I am a person of integrity and honesty. I mean what I say and I follow through with my commitments. I will push my desire to grow and improve. I prioritize my health and fitness goals with my resources, time, and energy. I am willing to follow the Foundry nutrition program for four weeks and learn new nutritional habits that will make a positive impact on my life.
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