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MW - Personal Nutrition Plan
Please fill out with all required information.
Without all information I won't be able to generate a personalized nutrition plan for you.
NOTE: If you have any questions/comments or bump into a rock, please e-mail me at
melissa@melissa-wellness.com
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Email
*
Your email
How did you hear about us?
*
Facebook Post
Instagram Post
Website (
www.melissa-wellness.com
)
Word of Mouth
Event
Other:
Full Name:
*
Your answer
Instagram handle:
Your answer
Best way to contact you (e-mail, Instagram DM, text). If text please provide your phone number.
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Your answer
Age:
*
Your answer
Sex:
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Female
Male
How tall are you? IN CM (centimeters) PLEASE!
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Your answer
What is your current weight? IN LBS PLEASE!
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Your answer
What is your current GOAL? Choose one.
*
Loose Weight (you want to lose 10-15 lbs or more)
Build Muscle (you want to build muscle and increase their overall body weight)
Athletic Performance (want optimal nutrition to support long and intense athletic training. Minimal to no weight change desired)
Body Recomposition (want to lose less than 10 to 15 pounds of body fat, while simultaneously building muscle)
Improve Health (want to improve their nutrition and overall health, while maintaining their current weight)
If you chose LOOSE WEIGHT or BUILD MUSCLE, how much do you want to weigh?
Your answer
What is your preferred eating style?
*
Anything - No major preferences or restrictions. Will eat practically anything.
Mediterranean - Features plant foods, healthy fats, and moderate amounts of lean protein.
Paleo - Emphasizes meats, vegetables, and healthy fats.
Vegetarian - A plant-based diet, plus small amounts of eggs and dairy.
Fully Plant-Based - All plant-based foods. No animal products of any kind.
How many meals do you want to eat each day?
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1
2
3
4
5
6
7
8
How ACTIVE are you each day? (not counting exercise)
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Very Light - Sitting most of the day (example: desk job).
Light - A mix of sitting, standing, and light activity (example: teacher).
Moderate - Continuous gentle to moderate activity (example: restaurant server).
Heavy - Strenuous activity throughout the day (example: construction work).
What best describes your WEEKLY workouts?
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Very light - Almost no purposeful exercise.
Light - 1-3 hours of gentle to moderate exercise.
Moderate - 3-4 hours of moderate exercise.
Intense - 4-6 hours of moderate to strenuous exercise.
Very Intense - 7+ hours of strenuous exercise.
Are you pregnant?
*
Yes
No
Are you breastfeeding?
Yes
No
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PAYMENT METHODS
In order to activate your plan, you must thoroughly fill out this form and make payment of $219.99 USD due. (If you are a prize winner please disregard this message.)
DISCLAIMER:
Please acknowledge your responsibility to work directly with a medical professional before, during and after seeking a nutrition consult. Any information here provided must not be followed without the authorization of your medical doctor. If you decide to utilize this information without said authorization, you are accepting full responsibility for your decisions.
ACCEPTANCE SIGNATURE:
*
Your answer
DATE:
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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