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Nutrition Consult
Basic Nutrition Consulting Info
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Name:
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Your answer
Email:
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Phone Number:
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Is texting is allowed to the provided phone number?
Yes
No
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Location (City, State)
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Age:
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Your answer
Height and Weight:
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Your answer
Body Fat %: (if known)
Your answer
Tell me a little about yourself, background, and anything specifically you have questions about.
Your answer
Medications:
Your answer
Nutrition Related Medical Issues: Please include any food allergies.
Your answer
Digestive issues: Examples include heartburn, bloating, gas, diarrhea, constipation, reactions to foods.
Your answer
Please list any supplements that you currently take (multivitamin, fish oil, protein powder, etc)? Please list brand names if known.
Your answer
How much water to do you generally drink a day?
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List any others fluids you generally drink and how much? (coke, coffee, alcohol/per week)
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How many hours of sleep do you get a night? Do you feel your sleep is high quality?
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Do you smoke?
Yes
No
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How would you describe yourself (out of shape, overweight, weak, tired, toned, fit, athletic, motivated)?
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Tell us a timeline of your weight fluctuations (when did you feel the best/worst)?
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What is your general goal?
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Weight Loss
Lean Out
General Strength
Maintain
Recovery/Rehab
Weight/Muscle Gain
Do you have a weight specific goal? If not please name a few specific goals you would like to achieve?
Your answer
What types of diets and/or fitness programs have you tried? What worked? What did not?
Your answer
Do you have any current food preferences? (Vegan, Paleo, Keto, Vegetarian etc)
Your answer
Current Vices?
Sweets/Chocolate
Alcohol
Salty foods
Soft Drinks
Late Snacking
Emotional Eating
Eating out or convenience foods
Other:
What describes your current eating habits? Check all that apply.
Eat more than 4 servings of fruit and veggies a day
Typically follow a low fat diet.
Actively limit added sugars.
Eat out/processed or convenience foods more than 5x/weeks
Rarely eat fried foods.
Use Sweeteners (Stevia, Splenda, SweetNLow etc)
Other:
Please list your typical food intakes through out the day (breakfast, lunch, dinner, snacks).
Your answer
Do you previously have any limitations, injuries, or any concerns with starting a new exercise and nutrition program?
Your answer
What best describes your current activity level?
Exercise 6x/week or more in a gym setting.
General Exercise/activity 3-4x/week
Moderately active 2-3x/week
Today is step one for me! :)
Other:
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On a scale of 1 to 10 what is your current ability level? 1-Injury free, 5-Some past injuries but nothing currently hurting/injured, 10-Injury within the last 6 months/chronic pain. Please list any limitations or injuries that may effect your exercise intensity level.
Your answer
What type of exercise or activities do you enjoy (sports, group exercise, weightlifting, hiking etc)?
Your answer
What motivates you (family, appearance, specific fitness event/race/competition)?
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Any additional information, goals or fitness/nutrition preferences you would like to include please list here.
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