Client Intake Form for One-Time Package
Please complete this form so I can build out your customized periodization plan, nutrition plan, and fitness program geared towards your lifestyle! 

Disclaimer:
The nutrition guidance provided by Athena Nutrition LLC is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any medical condition. It is not a substitute for medical advice, diagnosis, or treatment from a qualified healthcare provider. Clients are encouraged to consult with their physician or other healthcare professional before making any changes to their diet, exercise routine, or lifestyle—especially if pregnant, nursing, taking medications, or under medical supervision.

By completing this form, you acknowledge that you have read and understood this disclaimer and agree to take full responsibility for your health and well-being.

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Full Name *
Email Address *
Phone Number *
Date of Birth *
Height *
Current Bodyweight *
Goal Bodyweight *
Current Occupation *
What are your biggest goals when it comes to health, nutrition, and fitness? Check all that apply. *
Required
How many hours of sleep do you typically get per night? *
How would you describe your stress level on an average week?
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Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what? *
Which of those things worked well for you, and why?  *
Which of those things did not work well for you, and why not? *
Right now, how would you rank your overall eating and nutrition habits? *
Horrible
Amazing
Do you have any dietary restrictions, food allergies, or intolerances? *
Do you currently track your food or have you in the past? If so, with what app or method? *
Are there any foods or habits you struggle with or want help improving (e.g., late-night snacking, sugar cravings, binge eating, under-eating)? *
Do you eat out or order in frequently? If yes, how often per week? *
Do you consume alcohol? If yes, how often and how much? *
What has made it hard for you to stay consistent in the past? *
Which phrases sound most accurate when describing your eating habits? (Select all that apply) *
Required
Do you currently follow a fitness routine? If yes, describe it. (These questions are optional for Tier 1 packages)
How many days per week do you realistically want to train over the next 6 months?
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How long do you typically have for each workout? (30 min, 45 min, 60+ min)
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Do you have any past or current injuries or limitations I should know about? *
Are you training at home, in a gym, or both?
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What equipment do you have access to? (Describe in detail: dumbbells, kettlebells, resistance bands, barbell, squat rack, TRX, cardio machines, etc.)
What types of training do you enjoy (or hate)? (e.g., HIIT, strength training, CrossFit, running, yoga, etc.)
Is there anything coming up (vacations, work travel, life events) that could impact your routine in the next 6 months? *
Right now, how much do the people and things around you support health, fitness, and/or behavior change? *
Not at all
Completely
What does success look like for you 6 months from now? *
Right now, are you taking any medications, either over-the-counter or prescription? If yes, list all that apply. *
Right now, are you taking any supplements? If yes, list all that apply. *
Food Preferences: The next 3 questions will outline your food preferences which will help me in building out your nutrition playbook.

Red Foods: These are foods you dislike, are allergic to, you don't tolerate, or foods you cannot eat in moderation (trigger food). Please list all foods below:
 *
Yellow Foods: These are foods you can somewhat tolerate or digest ok, you could eat a little of it, or if it is mixed in with other foods. Please list all yellow foods below: *
Green Foods: These are foods you love, you digest well, they support your goals, you can eat them in moderation, etc. Please list all green foods below: *
Is there anything else you'd like me to know about you, your schedule, your health, medications, or your goals before I create your program? *
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