New Client Questionnaire

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Do you have any medical conditions?

YESNO

5

If yes, please explain.

6

Have you ever had a Nutrition Coach?

YESNO

7

If yes, did you have success? Any struggles? If no, what are you seeking with a Coach?

8

Have you ever tracked your macros before? Explain.

9

Current stats?

Age

Height

Weight

Waist & Hip Measurements

10

Activity level?

Sedentary Lifestyle (Mostly seated all day, little to no exercise)

Slightly Active (Some movement, 1-3 days of exercise a week)

Moderately Active (More movement, 3-5 days of exercise a week)

Active (Exercise daily, light movement for job)

Very Active (Intense exercise daily and/or labor intensive job)

11

Short Term Goals?

12

Long Term Goals?

15

16

Please upload initial progress pictures. Sports bra/shorts, bikini, or your own comfort level. (Front, Back, & Side View) Pick a flat background with good lighting. I will ask that every picture is taken at the same location & clothing,

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

17

During your first Month we will check-in weekly. Thereafter it will be bi-weekly. Which day works best for you?

Sunday

Wednesday

O

18

Spaces are limited, are you ready to give 100% dedication to your goals? I am your Coach, not babysitter. Your results will be a direct reflection of adherence to the small changes we make over time. It will take patience, grace with yourself, and an unbreakable self belief that you CAN do this. Are you ready?

YESNO