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201 Nutrition 6 Week Summer Shred
Intake Form
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Email
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Your email
First and Last Name
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Your answer
Phone Number
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Your answer
Date of Birth
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MM
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DD
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YYYY
Height
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Your answer
Current Weight
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Your answer
Gender
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Female
Male
Summary of current training schedule (frequency/ duration of sessions/ types of training)
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Your answer
Employment - What does your job look like? (sedentary or active) What does the rest of your day look like outside of training?
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Your answer
Previous diets you've tried. Were they successful? Why or why not?
Your answer
Summary of your daily schedule. (Please include sleep and wake times, meals, and workouts)
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Your answer
How much sleep do you get a night? Are you rested or tired in the morning?
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Your answer
Do you eat while doing other activities (work/ phone/ tv/ driving etc)
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Your answer
Current supplements
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Your answer
Current medications (if any)
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Your answer
Caffeine!!! Please include all sources of caffeine on a daily basis (including coffee, tea, pre workout, energy drinks, soda)
Your answer
Alcohol. How many drinks do you have a week, on average?
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Your answer
Food allergies?
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Your answer
Foods you avoid?
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Your answer
Females: Do you have a regular cycle?
Your answer
Do you have any injuries? Have you had any in the last few months?
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Your answer
What is your primary goal in working with me?
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fat loss
performance
muscle gain
Other:
Any other relevant information for me?
Your answer
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