EmailMe Form - Nutrition Intake Form

EmailMeForm

Thanks for choosing Wenzel Nutrition Coaching to guide you in becoming the best and healthiest athlete you can be.
Please complete this Nutrition Assessment to help me tailor your plan to you and help you achieve your fueling and fitness goals.

Note: All information you provide on this secure form will be kept strictly confidential.
Name
First Last
Email
Phone
### - ### - ####
Nutrition Coach Selection
My Wenzel Coach (if any)
Age
Sex
Male
Female
Prefer not to say
Getting to Know You
Knowing about your life, fitness goals and experience will help me tailor your nutrition package to best assist you.
What are you looking for most from this nutrition consultation? (List any nutrition/eating pattern/exercise goals you hope to achieve as a result of nutrition coaching.)
Tell me a little bit about your experience with your current sport
How open are you to looking at your current eating patterns and making changes if necessary?
Extremely open
Very open
Moderately open
Slightly open
Not at all open
Do you have any medical or mental health conditions that may impact the nutrition recommendations I provide you, i.e. diabetes, celiac disease, high cholesterol, depression, anxiety etc.? (If yes, please expand on any health conditions)
Please list any medications you are currently taking, if any
Do you smoke? If yes, how much and how often? (This includes tobacco, cannabis, vaping or any other form.)
Do you drink alcohol? If yes, how much and how often?
Tell me about your social/living situation (i.e bachelor, married with four children, etc) and job, indicating average level of daily stress on a scale of 1-low to 10-high.)
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Thanks for choosing Wenzel Nutrition Coaching to guide you in becoming the best and healthiest athlete you can be.

Getting to Know You