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PRISM Nutrition Coaching Form
Please answer all questions in as much detail as possible, to help ensure that we're a good fit.
I'll be in touch within 2-3 working days, and rest assured your answers will never be shared with any third party.
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Email
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Your email
Name
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Your answer
Gender
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Male
Female
Age
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Your answer
Phone number
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Your answer
Your weight in kilograms
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Your answer
Your height in metres
Your answer
Please describe any medical issues that could impact diet and exercise (e.g. diabetes, PCOS, thyroid)
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Your answer
Any food allergies or intolerances?
Your answer
What's your occupation? Describe your activity level (e.g. desk-based or active). Is it a high stress job?
Your answer
What type of coaching are you looking for? The investment for on-going coaching programmes starts from £6
99.
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Goal-Specific Programme (120-Days)
Premium Programme (90-Days)
Premium Programme (120-Days)
One-Off Consult (Nutrition Plan Only)
Unsure, I'd like your advice
What is your primary goal? Select ONE only.
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Fat Loss
Build Muscle/Strength
Get Fitter/Feel More Energetic
Enhance Performance
Other:
Please expand on your primary goal, quantifying your targets/expectations/previous experiences. If you have any secondary goal(s) in mind, please feel free to expand on this too.
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Your answer
Do you have a specific time-frame in mind as to when you'd like to achieve this?
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Your answer
In very simple, practical terms, what is preventing you from already having achieved your goal? For example, time, willpower, nutritional knowledge, portion control, food choices, cooking skills, exercise etc.
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Your answer
What's motivated you to make this change now?
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Your answer
What do you expect from me as your nutrition coach?
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Your answer
Are you currently training/exercising consistently?
Yes
No
Clear selection
What exercise/activity are you doing regularly now? Weight lifting, cycling, running, etc. How frequently do you do this?
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Your answer
Do you use an activity tracker that counts your steps? If so, what is your average step count over the past 7 days and past month?
Your answer
Lastly, where did you hear about PRISM Nutrition?
Your answer
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