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
Diabetes
High Blood Pressure
High Cholesterol / High Triglycerides
GI Disorder (IBS, Crohn's, constipation, etc.)
Heart Condition (e.g., arrhythmia, heart failure, coronary artery disease)
Kidney Condition (e.g., chronic kidney disease, kidney stones, reduced kidney function)
Cognitive or Memory Issues
Bariatric Surgery
Significant Weight Changes
None of the Above
Other
Do you typically eat breakfast?
*
Yes
No
How would you describe your eating pattern?
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3 meals daily
3 meals + snacks daily
1 or 2 large meals daily
Grazing all day
No consistent pattern
Do you eat at consistent times each day?
*
Yes
No
How often do you eat meals or snacks from restaurants, takeout, or fast food each week?
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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?
*
Yes
No
Anything else you'd like us to know?