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***PLEASE READ FULLY BEFORE CONTINUING: Nutrition coaching includes a detailed guide on macros and/or the hand portion guide, how to start tracking in myfitness pal, and my personal grocery list and recipe guide. We will have weekly check-ins through google sheets & forms & you may contact me through the MyPThub app or email during normal business hours (CST). Do you agree to these terms?
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PLEASE NOTE*** If you have already been eating too low of calories you will likely need a full reverse diet before I suggest a fat loss phase. I can help with this through coaching, but know it will require eating at maintenance calories for some time before cutting calories.
I will not put clients into further “cuts” or a lower deficit if I believe their body is maxed out on dieting. If you believe you are in this category & are not interested in a reverse diet, please consider this before you sign up for coaching with me! Do you agree to these terms?
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Full name:
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First Name
Last Name
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Email address:
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example@example.com
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Phone Number:
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Area Code
Phone Number
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Preference for contact
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Phone
Email
Text
Zoom or facetime
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7
How old are you?
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Sex:
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Female
Male
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Weight:
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Height:
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11
What type of coaching are you looking for?
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Fat/weight loss through a calorie deficit
Reverse dieting after long term chronic dieting
Reverse dieting after short term calorie deficit
Muscle building with surplus
Fat/weight loss through a calorie deficit
Reverse dieting after long term chronic dieting
Reverse dieting after short term calorie deficit
Muscle building with surplus
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12
What are your goals (choose all that apply):
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Muscle building
Strength building
Healthier food habits
Weight & fat loss
Lifestyle change
Metabolism repair
Better sleep
More energy
Maintain weight
Improve overall health
Look better
Feel better
Get control of eating habits
Improve athletic performance
Other
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13
Which goal is the most important to you and why?
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This is from the list you just checked.
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14
Do you currently do any cardio sessions?
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15
How many hours of cardio are you doing a week on average?
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None
0-2
2-4
4-6
6-8
8-10
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16
When doing cardio sessions, what type of cardio are you doing?
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17
What is your current weight lifting regimen?
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EX: How many days a week? How many hours a week? Are you taking classes or at the gym independently? Do you prefer lifting light or heavy weights? Do you implement progressive overload?
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18
What does your average daily schedule look like?
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Work, school, gym, kids schedules, etc?
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19
Approximately how many hours a week do you do other types of physical activity?
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EX: housework, walking to work or school, home repairs, moving around at work, gardening, etc.
fewer than 5 hours
5-9
10-14
15-19
20 or more
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20
How many steps do you get a day on average?
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21
Current nutrition regimen?
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EX: count calories or macros, intuitive eating, binge eating, no current regimen?
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22
Do you have any food allergies?
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If so, please list them.
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23
Any food preferences?
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EX: pescatarian, vegetarian, vegan
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24
Are you taking any supplements?
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25
Have you ever hired a nutrition coach before?
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26
How often have you dieted for weight/fat loss over the last 5 years? Have you tracked calories or macros? If so, what were your past numbers and goals?
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Please also specify timelines on how long you were using those specific numbers and if you're currently following them.
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27
Have you tried anything else in the past (or recently) to change your habits, your health, your eating, and/or your body?
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Which of those things worked well for you? Which of those things didn't work well for you? Why?
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28
Please answer all: Who lives with you? Do you have children? Who does most of the grocery shopping in your household? Who does most of the cooking? Who decides on most of the menu and meal types in your house?
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29
Any medical history that could affect physique goals?
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EX: hypothyroidism, hormonal imbalances, diabetes, PCOS, pregnant, nursing, etc?
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30
Are you ready to financially invest in coaching for a minimum of 12 weeks?
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12 weeks is the minimum for one on one coaching.
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31
What do you expect from me as your coach? What are you prepared to do to work towards your goals?
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32
Kailey Vecchione is not a physician or registered dietician. Please consult with your physician for medical clearance and approval before starting this nutrition program. Information provided will be in suggestion use only. It is not intended to diagnose, treat, cure, or prevent any health related problem- nor is it intended to replace the advice of your physician. You must be at least 18 years old to apply. By signing this form you agree to all of these terms.
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