Nutrition Coaching Intake Form
In order for me to be the best resource for you possible, please fill out the information below.

Please recognize the fact that it is your responsibility to work directly with your physician
before, during, and after seeking fitness consultation. As such, any information provided
is not to be followed without the prior approval of your physician. If you choose to use this
information without the prior consent of your physician, you are agreeing to accept full
responsibility for your decision.

Email address *
Name: *
Your answer
Age: *
Your answer
Weight: *
Your answer
Height: *
Your answer
Body Fat Percentage: (if known)
Your answer
Goal: *
How many times per week do you train/exercise?: (number of sessions per week) *
What is the typical duration of your training/exercise?: (number of minutes per session ON AVERAGE) *
Your answer
What do you do for a living: *
Your answer
What is the activity level at your job?: *
Readiness for Change/Motivation Level: *
Not Ready to Commit, Feeling a Little Apprehensive About Changing
Extremely Driven, Will Do Everything Necessary to Succeed
Do You Have a Specific Goal? Please Explain:
Your answer
How Will You Know You're Making Progress Toward Your Goal?: *
Your answer
Do You Have a Specific Timeline for Achieving This Goal? Please Explain:
Your answer
What Are Your Expectations From Me As Your Coach? *
Your answer
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