Nutrition Program Intake

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The information you share in this form will allow me to create your personalized nutrition guide.

This personalized guide help you come up with ideas and strategies that can help you make healthier food choices, control your portions, and show you how to make healthy eating effortless!

First and last name *

Email *

Phone number *

Age *

What is your biological sex? *

Male

Female

Prefer not to say

How tall are you? *

How much do you weigh right now? *

What is your goal? *

Lose weight (you'd like to use 5-10 lbs. or more)

Build muscle (you'd like to build muscle and or increase your overall body weight)

Athletic performance (you want to optimize your nutrition to support your sport)

Body re-composition (you want to lose less than 10-15 lbs. of body fat while building muscle)

Improve overall health (you want to improve your nutrition and overall while maintaining your current weight)

How much would you like to weigh? (if unsure right n/a) *

When would you like to reach this goal? *

What is your preferred eating style *

Anything (no major preferences or restrictions. Will eat anything)

Mediterranean (most plant foods, healthy fats, and moderate amounts of protein)

Paleo (emphasizes meats, veggies, and healthy fats)

Vegetarian (a plant based diet that includes small amounts of eggs and dairy)

Ketogenic (a high fat, very low carb diet)

Fully plant based (consuming only plants, and not foods that are from an animal of any kind)

Fully carnivore (only consuming meat)

Any preference on the amount of protein, carbs, and fats you consume? *

A balanced approach

High carb, low fat

Low fat, high carb

How many meals per day you prefer to eat? *

How active are you? (not including workouts or exercise) *

Very light (desk job)

Light (a mix of sitting and light activity, like a teacher)

Moderate (continuous gentle to moderate activity, like a restaurant server)

Heavy (strenuous activity throughout the day, like a construction worker)

What best describes your weekly workouts *

Very light (no purposeful exercise)

Light (1-3 hours of gentle to moderate exericse)

Moderate (3-4 hours of moderate exercise)

Intense (4-6 hours of moderate to challenging exercise)

Very intense (7 or more hours of very challenging exericse)

What are you struggling the most when it comes to your nutrition right now?

Any other points you would like to add about your nutrition goals and or preferences?

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