Nutrition Coaching Application Form

Nutrition Coaching Application Form

Shaped by Science
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
Age*
Height*
Weight*
Which Shaped by Science program are you most interested in (Programs here: www.shapedbysciencect.com )?*

Intensive 1:1 coachingProficient 1:1 coachingAccoutability coachingIntensive 2:1 coachingProficient 2:1 coaching
What approach to nutrition are you most interested in learning and applying?*

Macronutrient trackingIntuitive eatingBlend of bothOpen to conversation
What is your current goal?*

Fat lossBuilding musclePerformance in athletics or lifeImprove overall health and well being
What does a current WEEKDAY of eating look like from the time you wake up to the time you go to bed? Please do your best to include meal timing, portion size, etc. The more detail, the better.*
What does a current WEEKEND of eating look like from the time you wake up to the time you go to bed? Please do your best to include meal timing, portion size, etc. The more detail, the better.*
What is your alcohol intake like? How many drinks do you have per week?*
Please describe your fitness/exercise history and current protocols around movement in general (What kind of exercise? How many days per week? Do you go for planned walks? etc.).*
Do you have any health conditions I should know about? (History of eating disorder, diabetes, asthma, other conditions?).*
How many hours of sleep do you average per night?*
On a scale from 1-10 how stressed do you feel on a regular basis? (10 being I cannot function, 1 being very little stress).*
Is there anything else about you you feel I should know?
Were you referred by someone? If so, who?*
Do you have a start date in mind? If so, when?*
I understand that the program I sign up for has a minimum time and financial commitment of 6 months with no pauses. There are additional payment plans available upon request. I am ready to invest the time and energy my coach asks for.*

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