What is your name? *

Email *

What is today's date?

How old are you? *

What made you decide to schedule this nutrition coaching meeting? *

List any SPECIFIC GOALS you would like to achieve relating to your health, body, and performance. *

What's the BIGGEST OBSTACLE(s) keeping your from reaching that goal right now in regards to your nutrition? *

What are your BIGGEST STRENGTHS when it comes to NUTRITION? *

1-10 How motivated are you to make a change in your current habits to get the results you want? *

Do you have any experience in weighing/measuring and tracking your food? *

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? *

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?

Do you drink coffee or tea? *

COFFEE

TEA

BOTH (coffee & tea)

No

Caffeinated or not?

Caffeinated

Decaf

Both

Do you consume milk/dairy? *

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 *

Frequent Snacks

Please list your TYPICAL LUNCH 5+ days a week *

Please list all of your TYPICAL DINNER 5+ days a week *

Any snacks between dinner and bedtime?

Please CHECK the box of anything you currently do. *

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