The purpose of this form is to allow me to understand your present nutrition and personal needs in order to create an individualized plan for you.Your confidentiality is of the upmost importance and the contents of this application are intended solely for me and will not be shared. Name * First Name Last Name Email * Phone (###) ### #### Where do you live? Please provide time zone. Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Gender at birth and chosen gender Height Current Weight Ideal Weight Weight 1 year ago What are your goals? Lose weight / fat Gain weight/ muscle Maintain weight / lose fat Improve overall health Look / feel better Have more energy Improve physical or athletic fitness Get control of eating habits Which of your goals is the most important to you and why? Have you tried anything in the past (or recently) to change your nutrition and/or your body? Have you ever worked with a health, nutrition, or training coach? Which of those things worked well for you and why? (Even just a little bit and even if you're not doing them right now) Which of those things didn't work well for you and why? If you were to consider making more changes to your nutrition, what might that look like? Until now, what has blocked you or held you back from making those changes? On a scale of 1-10, how would you rate your overall eating and nutrition habits? Why? What time do you wake up and go to sleep? How many hours do you average? Do you fall asleep easily? Do you wake up in the middle of the night? On a scale of 1-10, with 10 being you wake up feeling energized and rested, how would you rate the quality of your sleep? Occupation What does your current work schedule look like? Do you currently workout? If yes, how many hours a week? To the best of your ability, describe your workout type. Do you have any experience weight lifting? Describe... Do you currently have a gym membership? If yes, which gym? If you workout at home, what fitness equipment do you have in your home? Approximately, how many hours a week do you do other types of physical activity (ex: walking to work/school, walking pet, moving around at work, gardening, home repairs, etc...) ? Have you ever tracked macros and/or calories before? If you know, what is your current daily calorie intake or macronutrient intake (protein/carbohydrate/fat)? Are you maintaining, losing, or gaining at the intake level you are eating now? Do you currently follow a specific diet (ex: vegan, vegetarian, pescatarian) ? Do you have any known food allergies or sensitivities? Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom: Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so, please explain: Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain: Are there foods that you crave? If so, please explain: What percentage of your meals are home-cooked? 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Relationship with food: ability to separate hunger from emotional need (using food to comfort, or in times of boredom, stress, etc.) Explain. What has your diet been like the past 6 months? Past 1 year? Past 5 years? Have there been major changes in dietary intake over these time periods? Have you struggled in the past, or do you struggle currently with food eating disorders? Explain. Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? If yes, please list. Please list any medications, either over-the-counter or prescription that you are taking currently or have in the past. Please provide relevant dates. Do you have any current or past use of hormonal birth control? If yes, please provide dates and type. How often did you take antibiotics in infancy/childhood? How often have you taken antibiotics as a teen? How often have you taken antibiotics as an adult? List all vitamins, minerals, herbs and nutritional supplements you are now taking. Please provide brands and dosages. Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? If yes, please explain. What do you expect from me as your coach? What would you like to learn? Thank you!
