Nutrition Coaching Intake Form
Age, Height, & Weight:
I don't workout regularly.
1-2x per week
2-3x per week
3-4x per week
4-5x per week
5-6x per week
When you do exercise or are physically active, what types of activities do you do and for how long?
Is there any forms of exercise that you particularly like over others?
What time do you typically go to bed at night and on average how many hours of sleep are you getting?
What is your reason for seeking out nutrition coaching rather than attempting to tailor your nutrition independently?
Please describe your nutrition goals in working with a nutrition coach.
Please list out a sample of your food intake on a workday (beginning with breakfast and make sure to include any drinks or snacks and the times you usually eat).
Briefly describe your meals on weekends. Does your intake and nutrition change drastically from the work week?
Do you have any food allergies?
Do you have any health issues I should know about?
Are you on any medications?
Do you have any foods that you extremely dislike or won't eat at all?
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