Ekoe Health Nutritional Intake Form
Please answer questions as specific as possible, the more data I have to evaluate,
the more I can determine what is best for you.
What is your name and address? *
Your answer
What is your email address and social media name (facebook / instagram)?
Your answer
What is the best way to contact you? (Please provide email / phone / facebook name). Where did you learn of Ekoe Health? *
Your answer
What is your sex?
What is your current weight? *
Your answer
What is your age?
Your answer
How tall are you in inches?
Your answer
What weight (in lbs) are you most comfortable? *this is not necessarily a number that you desire to be*
Your answer
Please add any comment about your above answer.
Your answer
What are your health goals, body composition goals and/or athletic performance goals? (are you looking to lose weight / gain muscle / get off meds, etc)
Your answer
Do you have any medical diseases or conditions affecting your health? Please list and explain how long you have had them.
Your answer
Are you on any medications or supplements? (please list and what condition prescribed)
Your answer
Please explain your desires for deciding to work with a nutritionist.
Your answer
How would you describe your activity level: sedentary, moderately active, very active, or a training athlete? Please describe your workouts/activity including frequency (ie 3 x a week, etc) and routines.
Your answer
Do you know, on average, how many steps per day you take outside of your formal exercise? This is usually determined with a step counter like a FitBit, Garmin, Apple Watch, etc.
Your answer
Are you interested in learning more about portion size and ideal protein, fat and carb intake? (this is called macronutrient balance)
Your answer
Are you currently tracking your food? If yes, please share your average daily calories and/or macronutrients from a typical week.
Your answer
Are you pregnant and/or nursing?
Do you have dietary restrictions such as diagnosed food allergies or known intolerances?
Your answer
Do you follow a particular dietary pattern such as vegan, vegetarian, pescatarian, ketogenic, paleo, etc.? (Please be specific about what you would not like on your meal plan, example, if you are vegan but eat eggs, or vegetarian but eat fish).
Your answer
Please describe how many meals/snacks you would like to eat per day (ie 3 meals + 2 snacks, 2 meals+ 1 snack, etc) and if you are interested in learning more about Intermittent Fasting.
Your answer
Do you experience undesirable symptoms when eating certain foods, for example, gluten or dairy products? Symptoms may include, but are not limited to: acne, anxiety, bloating, constipation, diarrhea, sinus congestion, upset stomach, lethargy, achy joints, inability to focus, etc.
Your answer
Please describe a typical entire daily intake (Example- Breakfast - 2 eggs and bacon, Snack - apple, Lunch chicken sandwich, etc)
Your answer
Please list what you drink during the day (tea, coffee with creamer, soda, water, etc).
Your answer
Do you suspect that you are undereating your calories? What makes you think that?
Your answer
What quality would your rate your sleep (0-low 10-high). How many hours to you get on average per night?
Your answer
Do you experience fluctuations in energy? Are there particular events or times in the day when you experience high or low energy? Please be specific in your description.
Your answer
Do you drink alcohol? If so, how many drinks per week do you enjoy? What type of alcohol do you prefer? Please be as descriptive as possible.
Your answer
Are you interested in learning more about healthy products that can support your organs and allow for whole body detoxification? *
Is there anything else about you, your goals or your lifestyle that you think we should know?
Your answer
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