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THRIVE WITH ME- 12 Weeks of Wellness
Welcome! I am so excited that you are interested in taking the next steps to become a a better you!
WHATS INCLUDED:
12 week (minimum commitment)
1:1 online coaching with Nutritionist Angie
Customised nutrition plans changed frequently to suit your goals and progress
Lifestyle plan and habit tracking via APP access
Fortnightly check ins via email and check in form
Unlimited support and accountability
Ongoing education and free nutrition resources
INVESTMENT: $
444 paid in full
or $44 per week via direct debit
*LIMITED SPACES AVAILABLE*
If you have any other questions please feel free to email me at:
angie@thenutritionclinic.com.au
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Email
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Your email
Full name
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Your answer
Age
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Your answer
Occupation
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Your answer
What can I help you with?
Nutrition & Lifestyle
Nutrition Only
Mindset
Weight loss
All of the above
Other:
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Do you have any diagnosed medical conditions? (E.g. Diabetes, Thyroid, Heart disease/High Blood Pressure, any injuries, PCOS). If yes- please specify
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Your answer
Are there any other health issues we should be aware of?
Pregnancy
Breastfeeding
Food intolerances
Allergies
Heart condition/high blood pressure
Medical devices/implants/joint replacements
Diabetes
Liver or Kidney disease
Thyroid condition
Eating disorder
Other:
Are you on any medications or supplementations ? If yes- please specify
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Your answer
What are your Short and Long term goals
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Your answer
What are you struggling with when it comes to reaching these goals?
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Your answer
What are you hoping to achieve
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Your answer
Describe your current relationship with food
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Your answer
What is your current exercise regime; Frequency, time of day, duration and type of exercise you do and enjoy:
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Your answer
Activity Levels
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Sedentary (little or no exercise/desk job)
Lightly Active (light exercise/sport 1-3 days a week)
Moderately Active (moderate exercise/sport 3-5 days a week)
Very Active (heavy exercise/sport 6-7 days a week)
Extremely active (very heavy exercise/physical job 6-7 days a week)
Other:
Current energy levels
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Cant get out of bed in the morning
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2
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10
Jumping out of bed
Stress levels
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Under control
1
2
3
4
5
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7
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9
10
Extremely stressed
How many hours of sleep do you get per night? Do you find it hard to fall asleep or stay asleep? Do you wake up feeling refreshed?
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Your answer
Do you experience any of the following digestive concerns?
Constipation
Diarrhoea
Reflux
Burping
Bloating
Discomfort
Nausea
Irregular bowel movements
Straining
Other:
Are you willing to commit and invest in feeling better within yourself everyday by making positive lifestyle changes for 12 weeks and to receive the support and guidance you need to achieve your goals?
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YES!
Maybe
No
Is there anything else you would like to add?
Your answer
Thank you for your time, please allow up to 3-5 business days to hear back from me. I look forward to working with you!
Angie- The Nutrition Clinic Co.
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