Macro Count + Consultation Questionnaire
Please complete this questionnaire with as much detail as possible. During our consultation, be prepared to dive into your dieting history, health and wellness goals, current nutrition and fitness routine, and more. All consultations come with a PDF recap of our conversation which will include your custom macro calculation, my nutrition recommendations for you, nutrition topics, food lists, and more. I look forward to speaking with you!
Name
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First Name
Last Name
Email
*
example@example.com
Gender
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Please Select
Female
Male
Gender assigned at birth
Age
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Height (in feet & inches)
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Current weight (in pounds)
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What is your main goal?
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Fat Loss
Maintenance (Maintain current weight)
Build Muscle (Bulk/Surplus)
Healthy eating & lifestyle habits to feel my best
Think of your ideal future self in 2 years. How do you want to feel? What do you want to look like? What's important to you? What do you want to be able to achieve?
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What's your biggest nutritional challenge?
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Dislikes cooking or doesn't know how to cook
Don't know what I should eat
Wine/alcohol
Lacks time to prepare meals
Eating out/taking out meals frequently
Binge eating
Sweet tooth
Eating quickly
Snacking when not hungry
Lack of planning
Skipping meals due to busy schedule
Family or peer pressure
Other
What is your activity level at your job?
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None-I sit at a desk all day
Low-I stand a lot throughout the day
Moderate-I walk around alot throughout the day
High- I'm constantly moving
What is your average activity level, outside of your job?
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Sedentary- little to no exercise
Lightly Active- light exercise/sports 1-3 days/week
Moderately Active-moderate exercise/sports 3-5 days/week
Very Active- heavy exercise/sports 6-7 days/week
Extremely Active-exercise/sports more than 1x per day
What is the average number of steps you get daily?
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What does your current workout routine look like? How many days per week, how long is each workout, types of workouts)
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Be specific! Types of workouts include strength training, yoga, pilates, HIIT, running, etc.
Have you ever tracked calories and/or macronutrients?
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Yes, I have tracked both calories and macros
Sort of-I have tracked calories, but not macros
No, I have not tracked calories or macros
If your currently track macros/calories, what are your current calorie and macro targets?
Do you currently have any dietary restrictions? (i.e. vegan, vegetarian, gluten free, dairy free, etc.) If so, please indicate below.
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Please describe your current nutrition regimen. Be brutally honest with what you're currently doing- not where you hope to be. No judgment here!
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What past diets have you done? When was your last diet? Please be as detailed as possible.
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Have you every been diagnosed with an eating disorder or struggled with an undiagnosed eating disorder? If so, please describe when/details below.
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How many times per week do you drink alcohol?
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Never
1-2
2-3
4+
How many times per week do you have fast food, dine out, or order takeout?
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Never
1-2
3-4
5+
What things in your life make you happy? What activities charge your battery?
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What do you hope to gain from this consultation?
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Is there anything else you'd like me to know? What specific questions do you have for me to address during our call?
*
Terms & Conditions:
By purchasing this service & using these resources, I acknowledge that I am 18 years of age or older and all of the information provided on this application is truthful, accurate, and complete. I acknowledge that Gina Diaz is a certified nutrition & macros coach. She is not a physician or registered dietitian. The contents of this program and resources should not be taken as medical advice and it is not intended to diagnose, treat, care, or prevent any health problem -nor is it intended to replace the advice of a physician. I will consult with my physician or qualified health professional before implementing any suggested or offered changes, additions, or alterations to my lifestyle. Any recommendations I follow for changes in diet, including the use of nutritional supplements, and lifestyle habits are entirely my responsibility. Gina Diaz is in no way liable for my health & safety. I hereby accept all risks to my health, including injury or death that may result from my participation in the program and I hereby release Gina Diaz, on my behalf and on behalf of my personal representatives, estate, heirs, next of kin, and assigns from any and all costs, claims, causes of action and damages arising from any and all illness or injury to my person, including my death, that may result from or occur as a result of my participation in the program, whether caused by negligence or otherwise. I understand my results cannot be guaranteed and results experienced by each client may vary. There are no refunds due to the service nature of products offered by Healthy Glow with Gina LLC.
I agree and understand the terms and conditions above.
*
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Macro Count & Consultation
This price includes a 1 hour consultation call, one-time customized macro count based on your goals and dieting history, and consultation recap PDF guide. *All sales are final*
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