Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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5
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7
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
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2012
2011
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1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Current weight?
Goal weight?
Height
Current fitness and/or nutrition goal(s):
Goals
What is your PRIMARY goal?
What is your SECONDARY goal?
What are your immediate goals - what would you like to achieve in the next 4-6 weeks?
What are your long term goals?
NUTRITION
Do you follow a specific eating style or diet?
Yes
No
If so, please state what and since when?
What are your FAVORITE meals and snacks (homemade, bought, restaurant prepared) ?
What are your favorite HEALTHIER food items?
What foods do you DISLIKE?
Do you have any food allergies or sensitivities?
What protein sources do you like to eat?
Whole Eggs
Egg Whites
Tofu
Tempeh
Plant based "meat-like" items
Vegetables (beans, legumes, grains, etc.)
Fish
Seafood
Chicken
Turkey
Pork
Red Meat
Other
What is a typical breakfast?
Do you eat lots of greens on a daily basis?
Never
Rarely
Occasionally
Always
Do you eat dairy (yogurt, milk, cheese, etc.)?
Yes
No
How many caffeinated beverages do you consume a day?
How many times a week do consume alcohol?
On average, how much water do you drink a day?
Describe your current supplement/vitamin regimen
Fitness
Are you a boxer or athlete?
Yes
No
If you are a boxer and have an upcoming fight, when is your fight scheduled?
-
Month
-
Day
Year
Date
How many days are you able to workout per week?
Do you currently have a workout/fitness plan?
Yes
No
If so what does it look like ? (Include type of activity, duration, day/time)
What is the activity level at your job?
none(seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
Do you ever workout fasted (on an empty stomach in the morning)?
What forms of cardio do you like/do best with ?
What are you weak points strength/muscle wise ?
What are you strong points strength/muscle wise ?
What areas do you want to improve on your body ?
SLEEP
On average, how many hours of sleep do you get a night?
How long does it usually take you to fall asleep once in bed?
Do you have issues staying asleep through the night?
Never
Rarely
Sometimes
Often
Very often
What time do you usually go to sleep?
Does this vary much on the weekend?
Yes
No
How many nights a week would you say you have a problem with your sleep?
How would you rate your sleep quality?
Very poor
Poor
Average
Good
Very Good
How would you rate your energy levels when you wake up in the mornings?
Very poor
Poor
Average
Good
Very good
How would you rate your energy levels throughout the day?
Very poor
Poor
Average
Good
Very good
How many times do you snooze your alarm in the mornings?
0
1
2
3+
LifeStyle
On a scale of 1-10 what would you rate your general level of anxiety/stress?
Do you have a support system in place?
How stressful do you consider your job?
Not stressful
Slightly stressful
Stressful
Very stressful
Are there any other things that cause you notable stress?
General Health
What does your daily schedule look like?
If you have any injuries, please list them.
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
If you take any supplements, please list them.
Please rate your readiness for change
1
2
3
4
5
6
7
8
9
10
Thank you for your interest in working with me! As a certified sports nutritionist, I am excited to work with you to uplift you to your highest potential. This 30-minute consultation call is designed to help me understand your current training, nutrition, and performance goals, and to see how we can take your game to the next level. During our conversation, I'll also be assessing if we're a strong fit to work together. I respect both your time and mine, so I only work with driven athletes who are serious about breaking through their limits and making real, lasting progress - both in and out of the ring. If you're ready to commit and push past what's holding you back, I'm excited to connect! Please make sure you're present and ready to focus during our call. If you have any questions or do not receive a confirmation link for any reason, please reach out to me at 248-459-1257.
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