Nutrition Plan Intake form

Custom Meal Plan Intake Form

Please answer as completely as possible. This form and your consult form the basis of your nutrition plan.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What time zone are you in?
What is your preferred day (M-F) and time (am or pm) for a consult?
Age
Gender
Height
Weight
What are your health and wellness goals?

Improve healthLive a healthier lifestyleLose Body FatIncrease muscle massLearn how to eat for my body type and goalsOther
Dietary sensitivities/intolerances

DairyGlutenNuts/ tree nutsEggsSoyShellfishOther
Special Diets:

VeganVegetarianPescatarianPregnancyBreastfeedingOther
Are you currently taking medications and or supplements? If yes, please list below:
List any medical conditions / considerations affecting your health:

High /low blood pressureHigh cholesterolDiabetesPCOSThyroid imbalancePerimenopause, menopause, or post-menopausePregnancy, breastfeedingDisordered EatingOther
Describe any circumstances that affect your lifestyle, e.g.: shift work, travel, young children, etc.
Do you eat any of these foods?

Greek yogurtCottage CheeseCheeseMilkNon Dairy Beverage (almond, coconut, oat milk)NutsProtein BarsProtein Shakes
Do you currently use protein powder? If so, specify what brand.
What are your favorite foods?
Which foods do you avoid / dislike?
How much water do you drink/ day?

90-100 oz./dayLess than 100 oz./dayI am not sure
How much coffee do you drink / day?

I don't drink coffee8 oz./day16 oz./dayMore than 16 oz./day
Describe your alcohol consumption:

occasional (0-2/ month)1-2 drinks/ week3-4 drinks/ weekmore than 5 drinks/ week
What hour is the hardest to stay on track with food?

MorningAfternoonAfter dinnerOther
What would be most practical for your schedule / lifestyle: 5 or 6 meals/day? (breakfast, snack, lunch, snack, dinner, optional after dinner snack)

5 meals6 mealsOther
Are you currently exercising? If so what, and how often?
Would you like to receive FREE quarterly seasonal recipes?

YesNo
Is there anything you would like me to know that I haven't asked you about?
Who can I thank for referring my services?
INTAKE AGREEMENT:

I certify that to the best of my knowledge the above information is correct and complete. I also understand that Brandy Flotten Fitness LLC (“Company”) assumes no responsibility for any illness, accident or injury I may incur from the use of the meal plan and services provided by Company. All individuals are strongly encouraged to consult with a physician before entering a non-medically supervised exercise and / or nutrition program. Client acknowledges that Company, its employees, representatives, and agents are not medical professionals, and do not diagnose or treat medical conditions. Client acknowledges that Company guarantees no particular fitness or health outcome.
I hereby acknowledge and agree to the above disclaimer:

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ACKNOWLEDGEMENT OF ASSUMPTION OF THE RISK:

As a client of Brandy Flotten Fitness (“Company”), an LLC registered in the Commonwealth of Virginia, I understand that the activities I will engage in at the direction of Company are inherently dangerous with the potential for causing injury or other damages. Company will advise you on nutrition practices. You engage in these activities entirely at your own risk.

I acknowledge the risks associated with physical changes are well-known by me, and that whether I engage in certain nutritional practices is entirely my responsibility. Injuries may occur even though no one has engaged in any negligent conduct.

From time-to-time, Company may refer me to other professionals, including physical trainers. Company has no responsibility for the advice of others, and I acknowledge that accepting the advice of other professionals I do entirely at my own risk.
Acknowledging these risks, I freely engage in nutrition services with Company:

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Should be Empty:

Custom Meal Plan Intake Form