Tell me about yourself

Tell me about yourself
Name*

First NameLast Name
Email*
example@example.com
City, State*
Age*

MonthDayYear
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 sensitivityLactose intoleranceSoyOther
How often do you consume dairy?*

1-3 times per week3-5 times per weekDailyI don’t eat dairy
Do you consume animal protein?*

1-3 times per week3-5 times per weekDailyI 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, bagelsYes. Eggs, bacon, toast, potatoes, sausageI usually skip breakfastOther
If you selected “other,” please specify *
Do you eat lunch? Please specify *
Describe your snacking*

Chips, cookies, crackers, doughnuts, candy, etcNuts, hummusRaw fruit or veggiesI don’t snackOther
If you selected “other,” please describe *
A typical dinner consists of*

Potatoes, rice, pastaGreen vegetables (greens, broccoli, string beans, etc)Animal protein (chicken, fish, beef, lamb, pork)Bread (pizza, burgers, sandwiches, etc)I don’t eat dinnerOther
If you selected “other,” please describe *
What time do you eat dinner?*

4pm-6pm6pm-8pm8pm-11pmI 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 active1-3 days per week3-5 days per weekI workout dailyI am not consistent
Please describe any workout activity(ies) you are engaged in*
I typically go to bed between:

7pm-9pm9pm-11pm11pm-2am2am-5am
Please check any applicable ailments:*

Fatigue when you wake upFatigue after you eatHeadachesMenstrual crampsTrouble sleepingDepressionAnxietyJoint painMucusAllergiesNightmaresPCOSOther
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

AgreeDo not agree
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