Period Restoration Program Intake Form
Thank you for signing up for Period Restoration Program! Please fill out the following information to help Derek and Kaitlyn prepare for your initial Nutrition Counseling session.
Name
*
First Name
Last Name
Age
*
Grade
6
7
8
9
10
11
12
Freshman
Sophomore
Junior
Senior
n/a
Sport / Profession
*
School
Position
*
Gender
*
Male
Female
Have you ever had a Period?
*
Yes
No
How many months ago was your last menstrual cycle?
*
How did you find Full Circle Sports Nutrition?
*
Google search (website)
Healthprofs Listing
Referred by coach/training center
Instagram
Twitter
Referred by someone else
Other
Training Center/Coach referred by (if applicable)
*
Who were you referred by?
*
Please specify:
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Height
*
Weight
*
Goal Weight
*
Medical Conditions
*
Please list any supplements you take (including vitamins and protein powders)
*
Please list any medications you currently take
*
Past or current injuries
*
Energy level during the day
*
1
2
3
4
5
6
7
8
9
10
Trouble sleeping?
*
Often
Sometimes
Never
Hours of sleep/night
*
4 or less
4-5
5-6
6-7
7-8
8-9
9-10
10+
Diet and Exercise
The following information will be vital for tailoring your plan to your exact schedule and capabilities
Food Allergies/Intolerances
*
Appetite Concerns?
*
Current workout/training/game schedule (please be specific with times/days)
*
Class/Work Schedule
*
Any foods you will NOT eat?
*
Please list your current nutrition challenges
*
Please list your current nutrition goals
*
Diet Recall
Please provide a brief, detailed food log of a typical day
Breakfast
*
Time
*
Snack
*
Time
*
Lunch
*
Time
*
Snack
*
Time
*
Dinner
*
Time
*
Snack
*
Time
*
Please list a few days and times you are able to meet for your initial session (via Zoom; 50-60 minutes). Please include what time zone you are in:
*
LOCAL Clients: Please select your preference for the first session:
Virtual (FaceTime or Zoom)
In-person (Florham Park, NJ)
No Preference
I acknowledge that by signing up, I am agreeing to a one-time charge of $320, which includes the one-hour session + unlimited email check-ins. If I need to cancel or reschedule my session, I will provide at least 24 hours notice in accordance with the FCSN cancelation policy (which is part of the Welcome Packet that is received upon signing up). *I also have the option for additional paid features, such as follow-ups and game/race day plans, as listed in the Welcome Packet.
*
Yes, I agree
Sign-up
Please fill out the payment before below to confirm your sign-up. Upon submission, you will be promptly emailed to schedule your first session.
PAYMENT
*
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Amenorrhea Program
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