Nutritional Consultation
YOUR PERSONAL DETAILS
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Current weight
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Preferably in KG.
Height
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Age
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About you: (Lifestyle, Occupation, Illnesses, Dietary Needs – NOT YOUR GOALS)
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Please complete in as much detail as possible.
PLEASE SELECT YOUR MAIN GOALS IN ORDER OF MOST IMPORTANCE
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Lose body fat
Gain muscle
Get stronger
Get fitter
Performance based
SECOND GOAL
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Lose body fat
Gain muscle
Get stronger
Get fitter
Performance based
THIRD GOAL
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Lose body fat
Gain muscle
Get stronger
Get fitter
Performance based
Please expand on your goals: (Quantifying your targets/expectations/timescale/previous experiences)
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Please complete in as much detail as possible.
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YOUR CURRENT DIET
How many meals per day do you currently eat on average?
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Do you eat very similar meals each day or are they more varied/ erratic: e.g. Bought packaged goods etc (Please expand)
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How does your weekly cooking and food schedule work?
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Do you tend to plan your meal for the week? Is there certain days you like to eat out or get takeaway?
Please write down a TYPICAL day’s food and drink:
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Are there any particular foods you tend to avoid or that don't agree with you?
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Are there any foods you particularly like?
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How would you describe your daily energy levels?
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Please include mornings, mid day and evenings, pre and post workouts
On average how many hours of sleep do you get per night?
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What is your caffeine intake like?
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How often would you have tea, coffee, coke, energy drinks, chocolate and in what quantities?
What is this typical day’s eating trying to achieve?
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What do you find the most challenging about your current diet/ nutrition?
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Do you currently use any supplements or medications?
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If YES, please list them with details? (Quantities, consumption, brands, etc)
Please list (with approximate dates) any supplements and in particular, medications (including antibiotics) you have used in the last year:
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SUPPORT
In very simple, practical terms, what is it that you need to do to achieve your goals?i.e. what can I do for you?
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The different services I offer vary in terms of the level of support, time and client effort required. To better help advise you on the most appropriate and effective service for your individual goals, please indicate the budget most applicable to your current situation.
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< £100/ Month
£100-£200/ Month
£200-£500/ Month
> £500
Please state your dietary requirements (i.e. any foods you can/will not eat):
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If we end up working together, what does success look like to you in 3 months?
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What does success look like to you in 6 months?
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What does success look like to you in 12 months?
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YOUR CURRENT TRAINING / LEVEL OF EXERCISE
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Rows
TYPE
DURATION
SPEED/DISTANCE/VOLUME
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
FEMALES ONLY: Please detail information relating to menstrual cycle length, frequency or if you are postmenopausal.
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Have you previously sought dietary advice? (If so, please expand)
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Do you own digital bathroom scales?
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Do you own digital kitchen scales?
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Where are you geographically based?
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Is there any additional notes or comments you would like to make?
Submit
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