Nutrition Information Questionnaire

Full Name*
Date*
MM slash DD slash YYYY
Email*
Are you currently taking any medications?*
- Yes
- No
If yes, please list them.
Do you have any food allergies?*
- Yes
- No
If yes, list them.
Are there any foods that you absolutely refuse to eat or which you’re particularly sensitive too (i.e. cause excessive gas, bloating, etc)?*

My CURRENT diet could be best characterized as (check all that apply):*
Have you ever followed a nutrition/meal plan before?*
- Yes
- No
If yes, which aspects of the nutrition/meal plan helped you the most, and which aspects did you struggle with most?
Have you counted calories and macros in the past?*
- Yes
- No
What is your approximate current daily calorie intake and macro % breakdown (if this sounds like gibberish, type gibberish ;0)*
How many meals (including snacks) do you currently eat per day?*
What ratio of your meals are prepared at home vs eating out? (i.e. 70/30)*
What is your favorite cheat meal?*
On average, how much do you spend on groceries per month?*

Are you currently taking supplements?*
- Yes
- No
If yes, please list the supplements you're currently taking (including the dosage and brand), and any others that you've responded well to in the past.
On average, how much do you spend on supplements per month?
When it comes to your nutrition, please share what you struggle with the most:
If we could design you the perfect meal plan to follow, what exactly would you be looking for?
If there is any other information you think might be relevant before we design your nutrition plan?*

Custom Coaching Client Form #3 (last one 🤪)