CFS Nutrition Intake Form
Let's get a little deeper into your nutrition background! While this may be lengthy, it is necessary for setting you up with the optimal plan to fit YOUR lifestyle and achieve sustainable change.

Disclaimer:
Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and /or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
Sign in to Google to save your progress. Learn more
Date of Birth
MM
/
DD
/
YYYY
Gender
Email
Mobile number
Preferred contact method
What are your goals? Check all that apply
How, specifically, would you like your habits, your health, your eating, and/ or your body to be different?
Of those changes, which ones feel most important/ urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/ or your body? If so, what?
Which of these things worked well for you, and why?
Which of those things didn't work well for you, and why not?
If you were to consider maybe making more changes to your habits, your health, your eating, and/ or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall eating/ nutrition habits?
Terrible
Incredible
Clear selection
Are you regularly active in sport/ exercise? If so, approximately how many hours per week?
Clear selection
What types of sport/ exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g. housework, walking to work, home repairs, moving around at work, gardening, etc)
Clear selection
What other types of movement and/ or activities do you do?
Who lives with you?
Do you have children? If yes, how many and what are their ages?
Who does most of the grocery shopping in your household?
Who does most of the cooking in your household?
Who decides on most of the menus/ meal types in your household?
Right now, how much do the people and things around you support health, fitness, and/ or behavior change?
Not at all
Completely
Clear selection
Have you been diagnosed (currently or in the past) with any significant medical conditions or injuries?
Clear selection
Right now, do you have any specific health concern, such as illnesses, pain, and/ or injuries?
Clear selection
Right now, are you taking any medications, either over-the-counter or prescription?
Clear selection
On a scale of 1-10, how would you rank your health right now?
Not in a good place
Great
Clear selection
In an average week, how many hours do you spend in paid employment?
In an average week, how many hours do you spend in taking care of others?
In an average week, how many hours do you spend at school or doing school work?
In an average week, how many hours do you spend doing other unpaid work (e.g. housework, errands, etc)?
In an average week, how many hours do you spend traveling and/ or commuting?
In an average week, how many hours do you spend volunteering?
Adding up all these activities, about how many total hours do you spend on these per week?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
My life is panicked and insane
My life is perfectly calm and relaxed
Clear selection
Think about all the activities you're involved in (e.g. work, school, caregiving, housework, travel). Then assess as best you can... Given all the demands of your life, what is your typical stress level on an average day?
No Stress
Extreme Stress
Clear selection
On average, how many hours per night do you sleep?
Clear selection
How do you normally cope with your stress?
How READY are you to change your behaviors and habits?
Not at all
Completely
Clear selection
How WILLING are you to change your behaviors and habits?
Not at all
Completely
Clear selection
How ABLE are you to change your behaviors and habits?
Not at all
Completely
Clear selection
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms