Nutrition Questionnaire Form

Name*

First NameLast Name
Email*
example@example.com
Cell Phone*

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Age
Gender
Height (Inches)
Weight (Pounds)
What is your body type? Endomorph (Stockier bone structures with larger midsection and hips, gains fat easily, loses it slowly), Ectomorphs (smaller muscles/bone structure - harder to gain muscle) Mesomorph (athletic build, medium bone structure, gains muscle easily, loses fat easily)
Have you had any previous eating habits that may/does impact your relationship with food? (Any history of eating disorders) If so, please describe.
Are you pregnant or nursing? If so, please state which trimester or how far postpartum.
How many steps do you get daily on average?
How many ounces of water do you drink a day on average?
Health & Fitness Goals
What goals do you hope to accomplish?*

Fat Loss (I want to lose weight/fat)Increased Muscle Mass (I want to build muscle)Maintenance (I dont want to lose weight, but want to change body composition - increase muscle/lose fat)Other
Out of all of these goals, which is the most important to you?*
Do you have a specific timeline for achieving that goal? If so, please specify:*
What do you see being the biggest challenges for you to accomplish your goal?*

Consistent ExerciseDietTime ManagementMeal PlanningChecking in with usSupport from family, friend, coworkersStaying focused on weekendsNothing, I'm ready to goOther
Is there anything else you would like to tell us about your health and fitness goal(s)?
Medical and Health Information
Do you have any diagnosed health problems, list condition(s). (Diabetes, heart disease, high blood pressure, hypothyroidism, etc)*
Do you have any physical limitations? (asthma, bad knees, back, wrists, etc)*
List any medications you are currently taking.
Any additional health information you would like to share? (Hereditary diseases, hunches on potential issues, food allergies)
Lifestyle Information
What do you do for a living/occupation?*
How would you best describe your activity level during the day?*

None, sedentary job, little activity at homeModerate, light activity during the day and at homeActive, on your feet most of the day but nothing strenousHeavy, on your feet and doing strenuous activity throughout the day
Does your work involve shift work?*

YesNo
Describe your work schedule, hours worked, time of day, days per week.*
Do you travel for work, if so how much?*
Tell us a bit about your family, if you have one, and weekly activities? *
When do you typically go to bed?*

:HourMinutesAM/PM Option
When do you typically wake up?*

:HourMinutesAM/PM Option
Describe your wake up routine. Do you need an alarm clock? Do you pop out of bed right away? Basically is waking up hard and how rested do you feel?*
What is your current meal planning/prepping style? Do you have any meal prep routines? Describe if so.*
Fitness, Diet and Nutrition Information
Explain your fitness/exercise routine? What kinds of workouts do you do? How frequently? Are you working with a trainer?
Do you take any nutritional supplements? If so, what supplements and what dosage?*
How many times a week do you eat out at restaurants?*
Do you follow any dietary guidelines? Vegan, Paleo, Pescatarian, etc? Also explain if you have any known food intolerances or foods you avoid. *
Macronutrient and Calorie Information
If you are currently tracking calories and macros, how long have you been tracking? If so, include your current target goals and how your progress has been following these.
If you are currently tracking and in a calorie deficit, how long have you been eating in a deficit?
What platform do you currently use to track your macros?
Thank you for taking the time to fill out this form and let us know more about you. If there is anything else you would like to let us know about concerning your diet, health, fitness, family, routines, work or whatever please do so below.
MACRO COACHING CLIENTS ONLY: Do you have a preference in your macro coach?
By completing this application, you are agreeing that you are atleast 18 years of age or older. You understand that this form is a preliminary application and not a contract for coaching unless this option was purchased through HLWATKINSFIT, LLC. You acknowledge that Heather Watkins and Olivia Lester are Certified Nutrition Coaches, and not physicians or dieticians. Your macronutrient goals should not be taken as medical advice. It is not intended to diagnose, treat, care or prevent any health problem or intended to replace the advice from a physician. Always consult your physician or qualified health care provider before starting any fitness or nutrition program. By submitting this application, you accept full responsibility for your actions.

YesNo
Should be Empty:

Health & Fitness Goals

Medical and Health Information

Lifestyle Information

Fitness, Diet and Nutrition Information

Macronutrient and Calorie Information