Nutrition Form Your Name: Preferred Name: Age: —Please choose an option—18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899 Preferred pronouns: —Please choose an option—he/himshe/herthey/themother Phone Number: Your Email: Weight: Height: Chest: Waist (directly above belly button): Glutes (at widest point): If we are not working towards a specific date, what would you like to get from this program? (body fat reduction, muscle gain, gain weight, eat healthier) What is your relationship and living status? Are you single, married, have a significant other and/or children? If you have a significant other, are they supportive of your nutrition? Willing to help you with improving nutrition? Are they healthy? Do they care what you do? Do you cook for others? Do you travel for work? If so, how often? When you travel can you pack your own food? What do you do for a living? How active are you for work? How many hours a day do you work? Do you stand or sit? Be specific on the hours you work and your activity level. Describe your average day from wake up to sleep. What time of day do you ideally workout? Please be detailed in what time you wake up and go to sleep and workout. If weekends are different include those days as well. Describe one day of eating from waking up to going to bed. Be as detailed as possible. If you measure food please give measurements. Do you use dressings, condiments? Include all beverages (alcohol too). Tell me the times of day you eat each meal. Describe your current fitness routine/training, including cardio. (days/week, hours per day, volume, frequency, exercises) How much water do you drink daily (in ounces)? How many meals do you eat every day? Snacks? How many meals are home cooked? How many meals ordered/fast food? Do you find yourself to be hungry often? When you get hungry what do you do? How important is food quality to you? (organic, non GMO, pasture raised, I don't care at all) Do you have food allergies or dietary restrictions (vegan, pescatarian, kosher)? Do you read food labels? —Please choose an option—yesno Are you familiar with macronutrients? —Please choose an option—yesno Do you know your current macronutrient intake? Calorie intake? Do you track it using an app? If so, which one? What are your favorite foods? What can you not imagine giving up? What are your least favorite foods? Do you take any vitamins/supplements? If so, list all. Do you take any medications? If so, list all. When was your last bloodwork? Did you have your vitamin levels and hormones checked? Were there any abnormalities? Is there something you really want to change about your eating habits? Pictures Front: Side: Back: (men in shorts, women in bikini) *jpg, jpeg and png formats (2mb limit) Δ
