Macro Coaching Questionnaire

Name*

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

Area CodePhone Number
Date of Birth*

YearMonthDay
Date
Height & weight
Health & Fitness Goals
What goals do you hope to accomplish?*

Fat LossIncreased StrengthIncreased Muscle MassWeight GainBetter DigestionMore EnergyBetter SleepOther
Out of all of these goals, which is the most important to you?*
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)*
List any medications you are currently taking.
Women only: are you in perimenopause or post-menopausal?
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?*
Are you a Clark County employee?
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
Who does the grocery shopping in your house? Who does the cooking? Do you have any meal prep routines?*
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?
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?
Thank you! If you are a Clark County Employee, you will receive an email from me regarding invoicing and scheduling.
Should be Empty:

Health & Fitness Goals

Medical and Health Information

Lifestyle Information

Fitness, Diet and Nutrition Information

Macronutrient and Calorie Information

Thank you! If you are a Clark County Employee, you will receive an email from me regarding invoicing and scheduling.