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Personalized Nutrition Report

Please answer the questions below to the best of your ability and with as much detail as possible, in order for us to create the best plan for you.
Once your assessment is reviewed and payment has been confirmed, you will be sent a personalized "User Guide" and report that will include:
- How to get started on your goals today + what to expect
- What foods to eat based on YOUR preferences
- Personalized portion tracker
- Personalized macro-nutrient goals and caloric needs
- How to eat the right calories and macros at each meal
- How to make adjustments and maximise your results + much more!
Nutrition Assessment

Payment is collected at the end of this form:
Full Name*

First NameLast Name
E-mail*
example@example.com
Contact Number
Age*
Height*
Please provide your height in centimetres.
Current Weight*
Please provide whether you are using pounds (lbs) or kilograms (kg).
What is your primary goal?*

Lose WeightBuild Muscle (increasing overall body weight)Athletic Performance (wanting optimal nutrition to support long and/or intense workouts)Body Recomposition (lose weight while building muscle)Improve Health (maintain current weight but improve overall health and nutrition)
Please describe this goal below (be specific):*
What is your expected goal completion date? Reminder: Results take time. Set a realistic date for yourself.*

MonthDayYear
Date
Please describe why you chose the date above:*
If you selected "Lose Weight" as your primary goal, please share what your target weight is.
Which option best describes your weekly purposeful exercise?*

Very Light (almost no exercise)Light (1-3 hours of gentle to moderate exercise per week)Moderate (3-4 hours of moderate exercise per week)Intense (3-4 hours of moderate to strenuous exercise per week)Very Intense (7+ hours of strenuous exercise - typically an elite athlete with multiple sessions per day)
Please provide more detail in terms of your weekly purposeful exercise described above:*
Which option best describes your daily activity level (EXCLUDING purposeful exercise)?*

Very Light (sitting most of the day, ex. desk job)Light (a mix of sitting, standing and light activity)Moderate (continuous gentle to moderate activity, ex. restaurant server)Heavy (strenuous activity throughout the day, ex. construction worker)
Please provide more detail in terms of your daily activity level described above:*
How are you spending your free time?*
What other types of movement and/or activities do you do?
What are your dietary preferences?*

Anything!PaleoVegetarianKetogenicFully Plant-BasedOther
If you selected a specific dietary preference above, please provide any additional information that may be useful to us when creating your report:
Do you typically prefer a specific macro-nutrient ratio?
Ex. Low Carb, Low Fat, High Protein, Other?
How many meals do you prefer to have per day?*
How would you rank your current overall eating/nutrition habits?*
From 1 (horrible), to 10 (awesome)
Have you been diagnosed with (currently or in the past) any significant medical conditions and/or injuries? Please describe them below:
Have you tried anything recently or in the past to change your habits, your health, your eating or your body? Please provide detail below:*
Based on your answer above, which of those things worked for you and why?
Again, based on your previous answer, which of those things DIDN'T work for you and why not?
How ready, able and willing are you to make a change?*
From 1 (not ready at all), to 10 (absolutely ready)
Is there anything else we should know?
Do you recognise that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation?*

Yes
Do you understand that all information provided is not to be followed without prior approval of your doctor? If you choose to use this information without such approval, you agree to accept full responsibility for your decision as we will not be held accountable.*

Yes
Please sign your name below to indicate that you agree and are ready to move forward with the report.*

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Personalized Nutrition Report
$80.00CAD

Total

$0.00CAD

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Personalized Nutrition Report

Nutrition Assessment