What is your name?
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Email
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What is today's date?
How old are you?
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What made you decide to schedule this nutrition coaching meeting?
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List any SPECIFIC GOALS you would like to achieve relating to your health, body, and performance.
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What's the BIGGEST OBSTACLE(s) keeping your from reaching that goal right now in regards to your nutrition?
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What are your BIGGEST STRENGTHS when it comes to NUTRITION?
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1-10 How motivated are you to make a change in your current habits to get the results you want?
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Do you have any experience in weighing/measuring and tracking your food?
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If yes to the above question, have you ever used an app like MyFitnessPal or something similar?
What do we need to know about you in order to coach you the best?
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What, if any, do you drink?
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Water
Coffee
Tea
Energy Drink
Milk
Nut Milk
Alcoholic Beverages
Soda
Juice
Sports Drinks
Calorie free sweetened drinks or diet drinks
Which of the following do you consume? (select all that apply)
Soda
Juice
Sports Drinks
Calorie free sweetened drinks or diet drinks
Brand(s)? Flavor(s)? Size of contain you drink from?
How much per day?
How much WATER do you drink on a daily basis (1 cup = 8 oz)?
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0 cups
1-3 cups
4-7 cups
8+ cups
Half my body weight in OZ each day!
Do you drink coffee or tea?
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COFFEE
TEA
BOTH (coffee & tea)
No
How do you take your coffee and/or tea?
Black / Just Water
Sugar
Sweetener (anything other than sugar)
Milk
Nut Milk
Flavored Creamer
Heavy Cream
Half & Half
Caffeinated or not?
Caffeinated
Decaf
Both
Do you consume milk/dairy?
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Yes
No
If yes, what kind of dairy?
Skim Milk
1% Milk
2% Milk
Whole Milk
How do you consume it?
In coffee or tea
Cereal
Drinking it from a cup
In or as part of a meal
Please list your TYPICAL BREAKFAST 5+ days a week
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Frequent Snacks
Please list your TYPICAL LUNCH 5+ days a week
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Please list all of your TYPICAL DINNER 5+ days a week
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Any snacks between dinner and bedtime?
Please CHECK the box of anything you currently do.
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Work currently (or have worked) with a nutritionist/dietitian
Follow a specific diet (i.e. Atkins, Vegetarian, Vegan, Low-Carb, Paleo, Gluten Free, etc.)
Purchase foods based on their 'Nutrition Facts' label
Regularly track food intake (with app, notebook, etc.)
Do not drink alcohol in any form
Fast daily
NONE OF THE ABOVE
Dietitian/Nutritionist Details
Who do you work with/who did you work with?
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From when to when?
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Tell us about your experience (in detail)
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