Personal Info
Full Name
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Date of birth
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Email
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Phone
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Deal Name / Internal Nickname
*
Preferred Method of Contact:
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Phone call
Text message
Email
Nutrition Goals & Priorities
What are your primary goals? (select up to 3)
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Improve overall nutrition & energy
Build muscle
Lose body fat
Improve digestion or gut health
Improve relationship with food
Increase athletic performance
Address fatigue or low energy
Other
Primary Goals description
What’s your top priority from the list above?
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Current Nutrition Snapshot
How would you describe your current eating habits?
Do you currently track your food intake?
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Yes — daily
Yes — sometimes
No
Do you have any dietary restrictions or preferences?
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None
Dairy-free
Gluten-free
Soy-free
Vegetarian
Vegan
Other
Allergy/Restrictions
Lifestyle & Activity
How active are you currently?
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Very active (4–6+ training sessions per week)
Moderately active (2–3 sessions per week)
Lightly active (1–2 sessions per week)
Mostly sedentary
What is your typical daily schedule like?
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Structured / predictable
Variable / unpredictable
Shift work
Other
How many hours of sleep do you get per night?
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<5
5–6
7–8
8+
Health & History
Do you have any known medical conditions that affect nutrition?
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No
Yes
Medical conditions
Do you currently take any supplements?
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No
Yes
Have you worked with a nutrition coach before?
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No
Yes
Motivation & Commitment
How committed are you to improving your nutrition habits?
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Commitment Level
What has been the biggest challenge in achieving your goals?
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How soon are you ready to begin?
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ASAP
Within 1–2 weeks
This month
Just gathering information
Final Details
Is there anything else you’d like us to know before your consultation?
*