EmailMe Form - Nutrition Consultation Questionnaire

Name *

First Last

Email *

Confirm Email *

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Coach I will be working with: *

Age *

Weight *

Height *

Waist measurement, in inches, at smallest portion of waist *

What is your goal? *

Fat Loss

Muscle Building

Body Re-composition

Increase Metabolism/Reverse Diet

Describe your past coaching experience *

Any previous coaching experience with a trainer or coach and any feedback (negative feedback is also welcome)

Describe in detail a typical weekday from the time you wake up to the time you go to bed *

Description of a typical day for you including work schedule, training schedule, meals eaten and times.

If you are currently employed, how many hours per week do you work? *

If you use an activity tracker, what is the average number of steps that you log daily? *

Are you responsible for any young children? *

Describe exactly what you ate and drank over the last 3 days (separate each day) *

How many ounces of water do you drink per day? *

How many alcoholic beverages do you typically consume per week? *

1 or less per week

2-4 per week

More than 4 per week

How many meals per week do you eat outside of your home? *

1 or less per week

2-4 per week

More than 4 per week

Describe your training regime *

Days per week you strength train, days per week you do cardio, length of time for each.

What is your current supplement regime? *

Please list all supplements and the amounts of each.

How has the current fitness and nutrition routine effected your weight and physique? *

Weight loss, maintenance, feeling leaner, photos improving, etc.

Do you have any major events, vacations, etc, coming up in the next 3 months? *

List your weight 3 months, 6 months, 12 months, and 18 months ago. *

Have you been diagnosed as diabetic, with kidney disease, or have a history of thyroid problems? *

Do you have any known hormone imbalances? *

Please list any known medical or food allergies, or dietary restrictions *

Special considerations (current or past injuries, surgeries, medical conditions, or medications, all past or present) *

Do you know what a macronutrient is? If so, please write the caloric amount per gram each macronutrient yields. *

Please tell me as accurately as possible how many calories per day you have been consuming? *

If they are not listed above, can you tell me foods you prefer and enjoy consuming? *

How many years of weight training experience do you have? *

Front of physique *

Side of physique *

Back of physique *

May I share your images on my personal social media channels? *

Yes, no, please ask before posting.

Facebook URL

Instagram URL

Who can we thank for the referral, or how did you hear about us? *