Name
*
First Name
Last Name
What would you like to be called (i.e. nickname)
Email
*
Date of Birth
*
MM
DD
YYYY
Phone
*
Country
(###)
###
####
Food Tracking
If you're using a nutrition tracking app, please share your username and password here (you can reset it after our work together):
Lifestyle Goals
*
In your own words, how do you think we can best help you with your nutrition and lifestyle goals?
Height
*
Weight
*
Goal Weight
*
Are you currently experiencing or have you experienced in the past any of the following conditions?
*
Check all that apply
Do you typically eat breakfast?
*
How would you describe your eating pattern?
*
Do you eat at consistent times each day?
*
How often do you eat meals or snacks from restaurants, takeout, or fast food each week?
*
0–1
2-4
5+
Please list any food allergies or intolerances.
*
Please list any other foods you dislike or are unwilling to try.
*
How would you describe your typical daily activity outside of exercise?
*
e.g., job-related tasks, commuting, household chores, hobbies, etc.
What types of regular physical exercise or planned workouts do you usually do?
*
e.g., walking, strength training, yoga, sports, classes
For planned physical exercise, how often do you do this each week?
Do you have any physical injuries or limitations?
*
Anything else you'd like us to know?
