Getting To Know You Name* First Last Phone*Email* Date of Birth* Month Day Year Current Age*Please enter a number from 18 to 99.Weight* Goal Weight* Height* Occupation?* Workout Schedule*How much time do you spend working out each week? What is your workout schedule like? If you're not working out now, do you plan to start? What activities appeal to you?*Mark N/A if already active.How many steps would you say you average per day?*Also how many hours would you say are spent sitting?Medications, Health Conditions or Food Allergies*Medications, health conditions or food allergies that could affect your metabolism or nutrition plan? Current or past conditions could apply.Diet History*Please give me a brief description of your diet history, including diets you’ve tried, for how long, and what was the outcome? Tell me specifically about the past 5 years.Willingness to unlearn what you've been taught.*Are you willing to unlearn everything you’ve been taught about low calorie and low carb diets? Yes No Unsure Normal Eating Habits*Please describe a normal day of eating for you on 1 week day and 1 weekend day.Supplements*Do you take any supplements? If so, please list.Water*How much water, in ounces, would you estimate you drink per day?Daily Schedule*Please list your typical week day and weekend schedules to help with planning meal and snack times.Willingness to be prepared*Are you willing to grocery shop, cook, and make sure you have food readily available? It can be prepared food, but you will need to be responsible for meeting your food needs daily, and planning ahead.Favorite Foods*List your favorite foods that you love to eat daily.Foods you HATE!*Trigger Foods*Do you have any trigger foods or what I like to call no limits foods? If it’s in your house, you will eat it ALL.What is your relationship to alcohol?*Do you smoke?* Yes No How much sleep do you get per night?*Stress Level*What is your daily stress level like? How do you manage it?I consider myselfCheck all that apply. a Stress Eater an Emotional Eater a Binge Eater Do you use food for comfort or reward?* Yes No Can you tell if you’re hungry or not?* Yes No Can you tell when you’re satisfied?*Can you tell when you’re satisfied? Or do you like to be FULL? How comfortable are you leaving food on your plate?Reality Check*How badly do you want to be done dieting and just feel good in your body and your life? Are you willing to invest the time, energy and take self responsibility to make this a reality?Comments, Questions or Feedback?Share additional comments, questions or feedback.
