Questionnaire for Nutrition Exclusive Coaching Plan! Please complete this questionnaire as thoroughly and honestly as possible so we can build a plan tailored to you. In-Take Form Personal and Background InformationHealth and Medical HistoryFitness and TrainingNutrition and HabitsLifestyle and MotivationAdditional Information First NameMiddle NameLast NameAgeGender- Select -MaleFemaleHeight:Current Weight (in kg or lbs):Occupation/Job:Sleep:Typical bedtime:Typical wake-up time:Average hours of sleep per night:Do you feel rested upon waking? Yes NoStress Level (on a scale of 1–10, 10 being highest):- Select -12345678910What other beverages do you regularly consume?How many glasses of water do you drink per day?PreviousNextCurrent Medications and Supplements:Existing Health Conditions/Diagnoses:Past Surgeries or Major Illnesses:Allergies or Intolerances:Digestive Health:Do you experience frequent bloating, gas, heartburn, or indigestion?How often are your bowel movements? Menstrual Cycle (for women):Is your cycle regular? Yes NoDo you experience any specific food cravings or symptoms related to your cycle?Blood Work/Lab Results:PreviousNextPrimary Nutrition Goal:Specific Target/Timeline:"Why" is this goal important to you?What is your biggest perceived obstacle to achieving your nutrition goals?PreviousNextHow would you describe your current diet?Number of Meals/Snacks per DayTypical Eating Schedule: (Approximate times for meals/snacks)BreakfastLunchDinnerSnacksFood Preferences:Favorite healthy foodsDisliked foodsFoods you cannot give upCooking Ability & Time:How often do you cook for yourself?How much time are you willing to spend preparing meals each day?Dining Out/Takeout Frequency:Alcohol Consumption:How many drinks per week on average?What type of alcohol do you typically consume?Cravings:What type of foods do you typically crave?When do these cravings usually occur?PreviousNextCurrent Exercise Routine:Please describe your current physical activity, including type, frequency, and duration.What time of day do you typically train/exercise?Post-Workout Nutrition:Non-Exercise Activity Thermogenesis (NEAT):How active are you outside of your dedicated workouts?PreviousNextIs there anything else you think your coach should know that could impact your nutrition plan?Are you currently tracking your food intake?What is your comfort level with tracking/measuring food?- Select -Highly comfortableWilling to tryPrefer not toWhat is your comfort level with tracking/measuring food? Previous Submit Form
