Nutrition Client Intake Form
Daphni's Strength + Nutrition
Name
First Name
Last Name
Email
*
example@example.com
Instagram name if applicable
*
Age?
*
Height?
*
Current Weight?
*
Ideal Goal Weight
*
What is your goal?
*
Please Select
Fat Loss
Maintenance
Surplus
How many steps per day do you average? (If you wear a fitness watch that tracks).
*
Your activity level?
*
Sedentary (little or no exercise, sit most of the day)
Lightly Active (exercise 1-3 days a week)
Moderately Active (3-6 days a week)
Very Active (5-7 days a week)
Extremely Active (6-7 days a week, sometimes two a days)
Outside of your training sessions, do you engage in any other physical activities (pickleball, cycling, running, etc.)?
*
Do you have any medical conditions or food allergies I should be aware of?
*
Have you ever been diagnosed with or struggled with disordered eating?
*
Do you currently have a workout routine? If yes, What does that look like? Enter NA if not applicable.
*
Please tell me what a typical day of eating looks like for you. How many meals a day? Please give me as much detail as possible.
*
How many alcoholic beverages do you have each week? (NA if not applicable)
*
Have you ever tracked your food before?
*
Please Select
Yes
No
Are you currently tracking macros? If yes, what are your current numbers for Protein, Carbs, and Fats.
*
Please list any health conditions that I should be aware of.
*
Do any of these apply to you?
*
Pregnant
Nursing
NA
Do you struggle with cravings? If so, what foods do you crave the most?
*
What would you say are your biggest struggles when it comes to nutrition?
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Do you eat out often? If so, how many times per week?
*
On a scale from 1-10, how committed are you to making nutrition changes?
*
What do you need the most support with? (meal planning, behavior changes, accountability, education, etc.)
*
Is there anything else you'd like me to know before we start?
*
Are you open to sharing a before/after photo to track your progress? This is completely optional, and your photos would never be shared without your permission.
*
Please Select
Yes
No
If yes, would you like your photos to remain private or be considered for sharing (without identity shown)?
Please Select
Keep private for personal tracking only
Okay to share anonymously
Okay to share publicly
Submit
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