Tell me about yourself
Name
*
First Name
Last Name
Email
*
example@example.com
City, State
*
Age
*
 -
Month
 -
Day
Year
Date
Height
*
Weight
*
Do you know your blood type? If so, please list below.
*
N/A if unknown
Are you prego? 🤗
If you are pregnant, what time do you take your prenatal vitamins?
Any known food allergies?
Celiac/gluten sensitivity
Lactose intolerance
Soy
Other
How often do you consume dairy?
*
1-3 times per week
3-5 times per week
Daily
I don’t eat dairy
Do you consume animal protein?
*
1-3 times per week
3-5 times per week
Daily
I don’t eat animal protein
Do you eat breakfast? Select which category of breakfast you generally consume
*
Yes. Mostly fruits (smoothies, fruit salad, cold pressed juice)
Yes. Doughnuts, cookies, bagels
Yes. Eggs, bacon, toast, potatoes, sausage
I usually skip breakfast
Other
If you selected “other,” please specify
*
Do you eat lunch? Please specify
*
Describe your snacking
*
Chips, cookies, crackers, doughnuts, candy, etc
Nuts, hummus
Raw fruit or veggies
I don’t snack
Other
If you selected “other,” please describe
*
A typical dinner consists of
*
Potatoes, rice, pasta
Green vegetables (greens, broccoli, string beans, etc)
Animal protein (chicken, fish, beef, lamb, pork)
Bread (pizza, burgers, sandwiches, etc)
I don’t eat dinner
Other
If you selected “other,” please describe
*
What time do you eat dinner?
*
4pm-6pm
6pm-8pm
8pm-11pm
I don’t eat dinner
Do you cook? (Please list how many times per week)
*
Average daily water intake?
*
How often do you drink juice? (Ex: 3 days a week or more)
*
How often do you drink coffee? (Ex: 3 days a week or more)
*
How often do you drink soda? (Ex: 3 days a week or more)
*
How often do you drink energy drinks? (Ex: 3 days a week or more)
*
How often do you drink alcohol? (Ex: 3 days a week or more)
*
Do you smoke?
*
Yes, often (4 days or more per week)
Yes, rarely (less than 3 days per week)
I don’t smoke
How many days per week are you active?
*
I am not active
1-3 days per week
3-5 days per week
I workout daily
I am not consistent
Please describe any workout activity(ies) you are engaged in
*
I typically go to bed between:
7pm-9pm
9pm-11pm
11pm-2am
2am-5am
Please check any applicable ailments:
*
Fatigue when you wake up
Fatigue after you eat
Headaches
Menstrual cramps
Trouble sleeping
Depression
Anxiety
Joint pain
Mucus
Allergies
Nightmares
PCOS
Other
If you selected “other,” please specify
*
Describe any health challenges you’ve been diagnosed with? (i.e. diabetes, cancer, fibroids, high blood pressure, asthma, hsv1, etc.)
*
Please describe any long or short term health goals
*
Are there any obstacles keeping you from your goals?
*
Are you taking any medications or natural supplements? Please describe
*
Do you need meal plan assistance?
*
Please note all information shared is confidential, and will not be disclosed to additional parties not affiliated with This Girl’s Grub/The Flora Fare, LLC. Consultations will take place via email and/or phone within 72 hours the completed form and payment have been received. Payment may go towards one remote cooking class within 30 days of consultation completion
Agree
Do not agree
Submit
Should be Empty: