Nutrition Client Intake Form

Name

First NameLast Name

Email*

example@example.com

Instagram name if applicable*

Age?*

Height?*

Current Weight?*

Ideal Goal Weight*

What is your goal?*

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?*

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?*

PregnantNursingNA

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?*

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.*

If yes, would you like your photos to remain private or be considered for sharing (without identity shown)?