Nutrition Information
Please fill out to the best of your ability. Once your form is complete, please allow 24-48 hours for Jenna to review your information and reach out to you! Thanks!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Communication:
What are your current health and fitness goals? Please be specific!
WHY are those goals important and meaningful to you?
What have you tried in the past? What has worked well? What has NOT worked well?
What are you willing to do/change in order to reach your goals?
What are you NOT willing to do/change?
What is your current age?
How tall are you?
What is your current weight?
If weight loss is a goal, approximately how much weight would you like to lose? You can state a short term and long term goal if you have a significant amount of weight to lose.
What has been most difficult for you when it comes to health, fitness, nutrition, eating habits, etc?
Tell me about your current lifestyle / routine / home life. What does a typical day look like for you?
Show me what a typical day of eating looks like for you.
If you currently exercise, how many times per week do you exercise and for how long? What type(s) of exercise do you do?
How many steps per day do you average (if you have a tracker)?
How are your stress levels currently, on a scale of 0 to 10 (10 = extreme chaos)?
How many hours of sleep do you average per night?
Do you drink alcohol? If so, how often and how much do you typically drink? (No judgment, I promise!)
Have you ever tracked your nutritional intake before (pen & paper, an app, etc)? If not, would you like to learn how to formally track in an app?
Do you have any idea how many calories you are currently eating on average?
Where do you typically exercise at, if applicable? What kind of exercise equipment do you currently have at home, or do you have a gym membership somewhere?
Are you interested in workout program options in addition to your nutrition plan? This would be an additional charge but we do have multiple workout programs to choose from, or I can write up personalized programs if desired.
Which option are you interested in? (3 months = most appropriate for <15-20 lb weight loss goal; 6 months = most appropriate for 20-30 lb weight loss goal; 12 months = most appropriate for >30-40 lb weight loss goal)
ONE TIME Calorie/Macro Consultation (sent via email)
In-person or Virtual Consultation only (45-60 minute session)
Initial consult + Monthly coaching (weekly check-in)
Initial consult + Monthly coaching (1x/month check-in)
How would you like to pay for your consultation or monthly coaching?
Venmo @Jenna-Maag
Cash - can be dropped off to 481 N Perry St. Ottawa (Building Resilience clinic)
Credit/Debit Card (4% fee will be added)
If you are signing up for a virtual or in-person consultation, what days/times would work best for you? If you selected an option where the plan will be emailed to you, then disregard this.
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