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Nutrition Pre-Consult Form
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Email
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Your email
Are you looking for coaching or a one-off consultation?
Coaching
Consultation
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Name
*
Your answer
Age
*
Your answer
Biological sex (if comfortable with stating)
Male
Female
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Height (cm)
Your answer
Weight (kg), if comfortable with providing this information.
Your answer
Waist measurement (1" above navel) if comfortable with providing.
Your answer
Reference: How to measure your waist
Average daily step count (last 7 days)
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Geographic location and time zone
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What prompted you to seek guidance with your nutrition?
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What are your current nutrition or health goals?
Your answer
What do you feel is currently holding you back from achieving these goals?
Your answer
Please provide details of any previous types of diets or diet plans you have followed.
Your answer
Do you currently feel, or have you ever felt, that eating can be a source of stress, anxiety or provoke feelings of unhappiness in your life?
Your answer
Do you currently exercise regularly? If so, please outline what your typical week in training looks like.
Your answer
What does your current eating schedule look like? Please outline a TYPICAL day of eating for you with the times that you eat and foods you consume at these times.
Your answer
Do you feel your eating habits change on the weekends? If yes, how so?
Your answer
Have you ever sought nutrition guidance before?
Your answer
Have you ever tracked calories or macros before? If so, what were your thoughts on this method of dietary monitoring?
Your answer
Do you currently use any dietary supplements or take any medications? If yes, please specify if comfortable with sharing.
Your answer
Please state any specific dietary requirements (i.e. any foods you cannot eat / or will not eat):
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In practical terms, what do you feel you need to do to achieve your goals?
Your answer
Do you currently smoke?
Yes
No
Other:
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Do you currently consume alcohol? If so, please list average units per week.
Your answer
Do you have any ongoing medical conditions that may require nutritional consideration?
Your answer
Do you suffer from any of the following?
Recurent headaches
Fatigue or periods of exhaustion
Frequent periods of low mood
Dizzy spells or lightheadedness
Constant thirst
How would you describe your energy levels throughout the day?
Your answer
How would you describe your current stress level and your ability to handle this stress?
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How did you hear about me?
Recommended by a friend or family member
YouTube
Instagram
Google search
Other:
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Is there anything else you that can think of that could potentially influence your health and fitness journey that I should be made aware of? Please add any notes here:
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Send me a copy of my responses.
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