Nutrition Discovery Form
Name
*
Prefix
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
Please enter a valid phone number.
What is your primary interested in connecting?
*
Quick boost to feel better / Break through a plateau
Simple recommendations to optimize my nutrition/supplementation/wellness further
I need a lifestyle change to prioritize getting healthier
Main Goal
*
Weight loss, fat loss, toning
Increased energy, mood, and/or sleep quality,
Increase recovery from exercise
Build lean muscle
Increased athletic sport performance
Rebalancing Hormones
Other
Previous Dietary Methods you've used in the past
Nutrition Cleanses and/or Fasting
Meal services (i.e. HelloFresh, Meals on wheels, etc.)
Meal Plans
Vitamins & supplements
None of the above
What kind of nutrition help would interest you most
Individual Nutrition Coaching with accountability and ongoing support
Being part of a Group Nutrition Program still catered to my goals (i.e. 30 Day Group Reset)
Basic recommendations for health products & supplements to know what could assist me towards my goals and healthier self
Physical activity in the past 2 months
*
None
1-2x/week
3-4x/week
>4x/week
Cardio workouts
Weight lifting
Stretching/Yoga
How would you rate your current lifestyle & Nutrition habits
*
Excellent
Average
Poor
Why do you give yourself the rating above?
*
i.e. Success would be if I feel more confident in myself, get back to a healthy weight, lifestyle, and...
My nutrition suffers because of: (select all that apply)
*
Struggle to be consistent with meal prep
Over-eating
Under-eating & missing meals
Eating out often
inconsistent meal times and/or portions
Unhealthy snacking
Do not like to cook
Underhydrated (less than 2.5L water per day)
I do not eat enough fruit and/or vegetables frequently
I would also be interested in the following to help my increase my physical activity and overall results:
*
1 on 1 Personal Training (Burlington/Oakville/Hamilton only)
Group Workouts (Burlington/Oakville/Hamilton only)
Catered workout programs to follow on my own
I am not on a exercise program at the moment and interested in focusing on nutrition alone
I workout and am highly satisfied with my current workout routine
Any changes you'd like to make in your lifestyle habits?
*
i.e. more exercise, quit smoking, go to bed earlier, feel less stressed, eat out less, drink less alcohol, etc.
How would you rate your stress levels?
*
Poor
Average
Excellent
What is your primary cause of stress?
How does stress manifest in your body?
How do you cope with your stress?
i.e. worry, eating, not eating, shopping, alcohol, etc.
Your Current knowledge of nutrition, fasting, and cleansing
*
Beginner
Average
Advanced
I have done (or am currently) following:
*
Time restricted eating (i.e. I eat between 11am and 7pm)
Intermittent fasting (i.e. I do 12/24/48 hour fasting x times per week/month)
Nutrient supported cleanses (low calorie, high liquid days)
Never done, but curious to know if they would benefit me
Not into fasting or cleanses
Please list any medications or supplements that you are currently taking or have been within the past 6 months?
Medical History
*
Diabetes
Cancer
Hypertension
Heart problems
High/low blood pressure
Hyper/Hypothyroid
Other
Your main health concerns (if any)
How many grams of protein do you consume on a daily basis?
*
Less then 80 grams of protein per day
80-120 grams
Consistently over 120 grams
No clue, probably fluctuates greatly
How often do you eat out per week
*
1-3x per week
4-6x per week
6 Meals or higher per week
Favorite restaurant/fast food?
How much caffeine do you have in a day?
Supplements I am currently using (or have used in the past 3 months):
*
Protein Supplement
Electrolytes
Collagen
Greens
Probiotics, Gut Health Specific
Stress & energy boosting Vitamins & supplements
Creatine, Bcass, pre-workout
Vitamins i.e. Magnesium, B12, D
Meal Replacements
Any other comments questions from above?
What differences would getting to your optimal health/fitness standpoint make for you?
Is there anyone that may be interested in joining you to help with their health/wellness/energy for extra accountability and enjoyment that may also want to chat?
Other:
As an entrepreneur, I love connecting with others outside of fitness & nutrition alone-- networking, making friends, and helping others connect. If any of the following interest you, please share :)
Beyond focusing on your own health, nutrition, are any of the following of interest to you?
Skin care, hair care, & beauty products
Making friends by being part of a health & wellness minded community
invitations to local health/wellness events for your own learning and/or professional networking
Learning more about nutrition from experts in the nutrition & wellness space
Health/Wellness brand partnerships (income, paid for products, events, increasing tax write-offs etc.)
Becoming, developing as, and/or connecting with other entrepreneurs
Other types of Coaching and/or seminar hiring (Life, Business, Corporate Wellness, Youth Wellness & Development)
For more Health, Fitness, & Wellness resources, visit:
www.superselfversion.co
m
Submit Info
Should be Empty: