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For Best Results Fitness & Nutrition LLC Nutrition Coaching Intake Form
Personal Information
Name
Prefix
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Job Position
Job Description
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Health Status
Weight (kg)
Height (cm)
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 (kg)
Reason for your nutrition diet
Please check below if you have any of the current health conditions:
Rows
Present
Not Present
Remarks
Gastrointestinal
Cardiovascular
Metabolic
Endocrine
Thyroid
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 disorder? If yes, please share it here so that we are aware about it.
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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
Do you drink energy drinks?
Yes
No
Do you go to gym?
Yes
No
What sports do you play?
How do you deal with stress?
How many hours do you normally sleep at night?
hours
Are you willing to change your habits?
Yes
No
Will you give your best to follow the nutritional plan?
Yes
No
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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: