SELF-LOVE AND FITNESS - INTAKE FORM
Thank you for participating in this program!

Based on the information provided in this form, we can make recommendations that are customized. All of our programs are built from scratch, which means that we need to ask many questions at the onset.

The level of intensity with recommendations will depend on you.

All client information is held under the strictest confidence.

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Full name *
By participating in this program, you are agreeing that you do not need clearance from a physician to participate in a nutrition or fitness program. *
Required
E-mail address *
Country, province (or state) *
Phone number (we would only communicate over WhatsApp or text if you enroll in a full-on program). *
Age or age range *
Approximate weight in pounds *
Height *
Body fat percentage if known? (This is not a big deal outside the context of competitors; however, it helps us figure out recommendations if losing fat was a goal of yours). Reach out if you want us to help you find out this information, but it is not critical since we do not sell weight loss, we sell sustainable lifestyle changes and athletic performance, which takes care of fat mass indirectly. *
Are you a smoker? *
Do you have any respiratory issues, i.e. asthma? *
No need to count or measure, but approximate caloric range currently per day, if known? I.e. 1800-2500, for example. Please write "unknown" if not known. *
Total amount of water per day in litres? *
Please list any allergies and food dislikes (i.e. ingredients or food types, be as detailed as needed). *
Total weekly alcohol consumption in glasses? *
Are you currently pregnant, breastfeeding, or postpartum? (If applicable). *
What is your current eating style? Do you follow a specific diet, such as paleo, keto, intermittent fasting? Please give us as much detail as possible on the current eating situation so that we can deliver accurate programming. *
Do you meal prep components of your meals ahead of time, if not, does this interest you? I.e. Preparing sides ahead of time, etc. *
If you are cooking for a family or meal prepping for a family, does everyone eat similar foods or is it different diet preferences overall? *
Our hair, skin, and nails can show signs of nutrient-deficiency and inflammation within the body, how would you rate all three? *
Required
Do you have a history of eating disorders or disordered eating? *
Required
Do you have any of these existing health considerations that we should think about when making recommendations for fitness and nutrition? *
Required
Preferred method of grocery shopping? Please check all that apply. *
Required
Nutrition and fitness goals *
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Current supplements *
Required
Favourite take-out restaurant and overall comfort-food style meals and how often per week? (We will never ask anyone to eliminate all fun foods, but we need an idea of type of food and frequency). *
Amount of weights you can lift in pounds - using both hands (dumbbells or kettlebells)? There is no right or wrong answer. *
How many walks do you take per week and for how long? (If applicable). *
When do you workout, morning or evening, and how many days a week? (If applicable). *
Please describe current bodyweight or weightlifting routine, if applicable. *
Do you enjoy running, walking, sprinting, or jogging? Check all that apply. *
Required
Are you currently following a program for fitness or nutrition or both, if so, how is it going? Adherence to a plan is much more about the fit between the person an the plan, rather than a reflection of the person's capability. What did you like or dislike about past programs? Why? *
Please let us know if you do want us to include a range of macronutrients (protein, fat and carbs) customized to your needs in our recommendations. *
Required
Would you like general supplement recommendations? *
Required
Would you like protein powder recommendations (provided this is safe for you in the context of your unique needs)? We ask because even if you are getting the RDA (Recommended Daily Allowance, it is still too low). Protein maintains a high metabolism. *
Required
Would you like general exercise recommendations? While this would not be a full-on workout plan, we could recommend styles of exercise that may be suitable for your goals if you like. *
Required
Thank you for your participation! Please share anything else you would need us to consider when creating your recommendations.  Any existing medications that have an impact on appetite and fitness routine? *
How is the quality of your sleep? *
What file storage system do you prefer to deliver your program to you? *
Required
Whether you signed up for the consultation + recommendations or recommendations-only program, provided that you are satisfied with the service, would you be willing to write a review? *
Required
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