Nutrition Questionnaire Form
This form will detail any background information required prior to starting nutrition coaching with Emily Eaton.
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First Name *
Last Name *
Email *
Phone Number
Birth Date *
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Which type of nutrition coaching are you interested in? *
Please list any medications or supplements your are taking. *
How would you rate your current eating habits? *
How much water do you consume daily? *
How many cups of coffee/tea/stimulants do you consume daily? *
How many glasses of alcohol do you consume a week? *
Have you ever tried a specific diet? Please explain your experience, emotions and results. *
Have you ever tracked your food using an app or tracking system? *
How often do you eat out/order food? *
Check off your typical daily meals/snacks *
Required
Would you consider yourself a salty or sweet snacker? *
Please list your food allergies, sensitivities or aversions. *
Do you have any questions/comments/concerns prior to starting nutrition coaching?
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