Nutrition and Lifestyle Intake Form
Used to assess habits, health, and metabolic body type
Personal Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Age
Current Weight
Current Height
Gender
Male
Female
What is your daily exercise activity level?
Sedentary (0-1 workouts per week)
Average (2-3 times per week)
Active (4-7 times per week)
Occupation
My occupation activity levels
At work I am in an office sitting at a desk for 6-10 hours a day
At work I am on my feet walking and moving around throughout the day, but not really increasing my heart rate
At work I am moving around most of the day, and sometimes break a little sweat
Other
Back
Next
Health Status
What are your fitness or nutrition goals?
Lose weight
Maintain weight
Gain muscle
Improve health
Become more active
Improve physical appearance
Improve personal development
Avoid medical complications
Ordered by the doctor
Other
Desired Weight (lbs)
Please check below if you have any of the current health conditions:
Rows
Present
Not Present
Remarks
Gastrointestinal
Respiratory
Cardiovascular
Neurological
Dermatological
Musculoskeletal
Urinary
Reproductive
Metabolic
Endocrine
Do you have any allergies? If yes, please list them down below and provide a description.
Are you currently taking any medications? If yes, please list them below:
This includes vitamins, supplements, and other medications you're taking
Do you have any eating disorders? If yes, please share it here so that we are aware about it.
Cravings play a critical role in our approach to matching your metabolic body type and understanding what you’re body is craving. Do you get cravings for certain types of foods?
Yes
No
If yes, what foods do you crave?
Back
Next
Body Type
Your metabolic body type is key in determining the best nutrition plans for your goals.
My shoulders are:
Wider than my hips
Same width as my hips
Narrower than my hips
A pair of relaxed jeans that fit my waist will be
Tight around by glutes
Loose around my glutes
Sit perfectly on my glutes
If I wrap my thumb and middle finger around my wrist, the two fingers they:
Don't touch
Barely touch
Overlap
Which of the following describes your current thoughts on your body goals?
I am soft. I need to lose 5-10 pounds and tone up my stomach, butt and arms
I need to lose 20 or more pounds and build some more muscle
I am skinny. I want a rounder butt and stronger looking legs
When it comes to weight gain and weight loss
I lose and gain weight easily
I have trouble gaining weight in terms of muscle or fat
I gain weight easily and have trouble losing it
Back
Next
Health Status
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Are you a vegetarian?
Yes
No
Are you pregnant? (women)
Yes
No
Do you consume a lot of meat in a daily basis?
Yes
No
Do you drink caffeinated beverages?
Yes
No
List your favorites meats/proteins.
Do you drink energy drinks?
Yes
No
What sports do you play?
How do you deal with stress?
How many hours do you normally sleep at night?
hours
Sleep quality is just as important as the amount of sleep you get. How is your sleep pattern?
Pretty good. I wake up feeling refreshed
Restless. I usually wake up one or more times during the night and regularly have trouble falling asleep or staying asleep
I toss and turn and/or can’t shut my mind off (difficulty falling asleep)
How many hours per week can you give for this nutrition plan, and its components such as grocery shopping and meal prep?
hours
Are you willing to change your habits?
Yes
No
Will you give your best to follow the nutritional plan?
Yes
No
What are your expectations from this coaching sessions?
Back
Next
Acknowledgment
I hereby certify that all information about my health condition and nutrition are accurate and true with the best of my knowledge. I understand that I am responsible for consulting my physician or health care provider about this nutrition consultation. I release this institution and its employees from any liabilities,claims, and demands that may arise during this consultation.
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: