Name: Name Email: Gender: Age: Height: Weight: How long have you been at this current weight? Body Fat % (if known): Waist Circumference: (in inches) Hip Circumference: (in inches) Desired Weight (Goal): Desired Body Fat % (if known): Goal Date (Note*: Without exercise, no more than 5 pounds of weight should be lost per week): MM slash DD slash YYYY Occupation: On a scale of 1-10, how intense are your stress levels? 1 being non-existent, 10 being very high. Does your job require a lot of sitting? On average, how many hours per day do you sit? Are you currently taking any medications? If so, please list: Do you have any injuries or illness I should be aware of (please include food allergies): Are you open to vegetarian or vegan options within your nutrition program? Foods you absolutely cannot eat: Favorite Foods (healthy): Do you have a specific type of protein, multivitamin, fat burner, probiotic, muscle builder, etc. that you enjoy or take on a regular basis? If not, would you be open to incorporating these into your meal plan to achieve the desired results? Motivation (what is driving you to make some lifestyle changes): What time do you typically wake up? What time do you typically go to bed? What time do you typically workout (if applicable)? How many times a week do you typically workout (if applicable)? Lifestyle: (circle one) a) Sedentary: At work – you work in an office At home – You’re usually sitting, reading, typing or working at a computer Exercise – you don’t exercise regularly b) Light Activity: At work – you walk a lot At home – you keep yourself busy and move a lot Exercise – you participate in light exercise or take long walks c) Moderate Activity At work – you are very active much of the day At home – you rarely sit and do heavy housework or gardening Exercise – you exercise several times a week and push yourself pretty hard d) Very Active At work – you hold a labor-intensive job such as construction worker or bicycle messenger At home – you are very active with heavy lifting and other rigorous activities Exercise – you participate in physical sports such as jogging or mountain-biking each day. Please describe to me what YOU think a healthy nutrition program would look like for one day:Please list your top 5 healthy foods:Please list your top 5 “unhealthy” foods (indulgences you crave):Please list foods that you do not like:Ideally, how many meals a day would you like to eat? Please indicate all of the protein sources that can be a regular part of your diet:Egg WhitesWhole EggsChicken BrestsCanned TunaBeansGreek YogurtWhite FishSalmon80-96% Extra Lean Ground BeefSteak (flank, fillet, top sirloin)Protein PowderPork TenderloinOtherPlease indicate all the carbohydrate sources that can be a regular part of your diet:Old Fashion OatmealSports DrinksWhole Wheat TortillaQuinoaCream of WheatBerriesBrown RiceCouscousWhole Wheat PastaYams/Sweet PotatoesBarleyFibrous VeggiesFruitsPopcornPeasOtherPlease indicate all the fat sources that can be a regular part of your diet:Coconut OilExtra Virgin Olive OilButterPeanut ButterNatural Almond ButterMixed Raw NutsAvocadoOtherPlease list any other comments, questions, or concerns:
