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Personal Brain & Body Nutrition Plan Intake
Please fill out the following form to the best of your ability. I will use these answers to create your custom nutrition plan! All answers are completely confidential!
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Name
Your answer
Email
Your answer
How would you like for us to do our weekly check-ins? We can email throughout the week with any questions you may have, but once a week you will be provided with new information & we will discuss your progress!
Email
Phone Call
Zoom
Facetime
Other:
Clear selection
Age
Your answer
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Weight
Your answer
Height
Your answer
City, State
Your answer
In general, what are your health/wellness/fitness/physique goals? Select all that apply.
Lose weight
Gain weight
Maintain weight
Gain energy
Improve mood
Improve sleep
Reduce stress
Reduce pain
Learn about being healthy
Other:
Rate the following three on your level of interest (1 is most interested, 3 is least): Increased energy, improved mental wellness/mood, lose weight/body goals
Your answer
Tell me a little bit about your personal health journey
Your answer
What did you eat & drink yesterday? Is this typical?
Your answer
What have you eaten & drank today?
Your answer
What does a typical day of eating look like for you?
Your answer
What do you typically drink in a day?
Your answer
On average, how much water do you drink per day?
Your answer
On a scale of 1-10 (1 being awful 10 being amazing) what is your average daily mood?
1
2
3
4
5
6
7
8
9
10
Clear selection
On a scale of 1-10 (1 being awful 10 being amazing) what is your average daily energy?
1
2
3
4
5
6
7
8
9
10
Clear selection
What is your daily activity level?
Sedentary
Lightly active
Active
Very active
Clear selection
Do you take any supplements or medications? If so, which ones?
Your answer
Do you exercise? If so, how often, and what do you do?
Your answer
Do you prepare your meals at home most of the time? If not, what do you do?
Your answer
Do you follow a special diet? (Gluten free, vegan, vegetarian, keto, paleo, etc.) If so, what?
Your answer
What foods will you ABSOLUTELY not eat?
Your answer
What are your favorite foods?
Your answer
What foods & drinks do you love but know might not be the best for you?
Your answer
For the mini pantry makeover please list 5-10 items in your pantry, including the brand & any specifications:
Your answer
Are there any other things you think I should know?
Your answer
YOU'RE DONE!
Thanks so much for completing this intake form! I will go over your answers and create your custom brain & body nutrition plan so we can have a great starting point for your 5 week nutrition & health coaching!
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