Nutrition Consult
Basic Nutrition Consulting Info
Name: *
Your answer
Email:
Your answer
Phone Number:
Your answer
Is texting is allowed to the provided phone number?
Location (City, State) *
Your answer
Age: *
Your answer
Height and Weight: *
Your answer
Body Fat %: (if known)
Your answer
Tell me a little about yourself, background, and anything specifically you have questions about.
Your answer
Medications:
Your answer
Nutrition Related Medical Issues: Please include any food allergies.
Your answer
Digestive issues: Examples include heartburn, bloating, gas, diarrhea, constipation, reactions to foods.
Your answer
Please list any supplements that you currently take (multivitamin, fish oil, protein powder, etc)? Please list brand names if known.
Your answer
How much water to do you generally drink a day?
Your answer
List any others fluids you generally drink and how much? (coke, coffee, alcohol/per week)
Your answer
How many hours of sleep do you get a night? Do you feel your sleep is high quality?
Your answer
Do you smoke?
How would you describe yourself (out of shape, overweight, weak, tired, toned, fit, athletic, motivated)?
Your answer
Tell us a timeline of your weight fluctuations (when did you feel the best/worst)?
Your answer
What is your general goal? *
Do you have a weight specific goal? If not please name a few specific goals you would like to achieve?
Your answer
What types of diets and/or fitness programs have you tried? What worked? What did not?
Your answer
Do you have any current food preferences? (Vegan, Paleo, Keto, Vegetarian etc)
Your answer
Current Vices?
What describes your current eating habits? Check all that apply.
Please list your typical food intakes through out the day (breakfast, lunch, dinner, snacks).
Your answer
Do you previously have any limitations, injuries, or any concerns with starting a new exercise and nutrition program?
Your answer
What best describes your current activity level?
On a scale of 1 to 10 what is your current ability level? 1-Injury free, 5-Some past injuries but nothing currently hurting/injured, 10-Injury within the last 6 months/chronic pain. Please list any limitations or injuries that may effect your exercise intensity level.
Your answer
What type of exercise or activities do you enjoy (sports, group exercise, weightlifting, hiking etc)?
Your answer
What motivates you (family, appearance, specific fitness event/race/competition)?
Your answer
Any additional information, goals or fitness/nutrition preferences you would like to include please list here.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy