Get Started with Nutrition Coaching

1
Name* This field is required.
First Name
Last Name
2
Birthday* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Male
Female
Other/Prefer Not to Say
4
Location* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Email* This field is required.
example@example.com
6
Mobile Number* This field is required.
Area Code
Phone Number
7
How would you like me to contact you?* This field is required.
Call
Text
E-Mail
8
Height in Inches* This field is required.
9
Weight in Pounds* This field is required.
10
Occupation* This field is required.(also let me know if you are a student!)
11
What exercise activities do you currently take part in and how often?* This field is required.e.g., running, weightlifting, group classes, etc. & frequency
12
Do you partake in any recreational physical activities? If yes, which one(s)?* This field is required.e.g., golf, skiing, hiking, kayaking, etc.
13
Do you have any additional hobbies?* This field is required.e.g., gardening, fishing, reading, cooking, etc.
14
What are your goals?* This field is required.
Fat Loss
Muscle Gain
Health Improvment
Other
15
On a scale of 1 to 5, do you consider your overall diet to be healthy?* This field is required.
1: Not at All Healthy
2
3
4
5: Extremely Healthy
16
Are you currently following any kind of diet? If so, what diet and for what reason(s)?* This field is required.e.g., Vegan, Paleo, Mediterranean, Ketogenic, etc. & why?
17
Are you currently taking any nutritional supplements? If so, what are they?* This field is required.e.g., vitamin D, iron, creatine, magnesium
18
On a scale of 1 to 5, how effectively are you able to control your temptations for junk food?* This field is required.
1: Not at All Effectively
2
3
4
5: Extremely Effectively
19
How many alcoholic drinks do you consume per week?* This field is required.
None
1-2
3-5
6-9
10 or more
20
How many caffeinated beverages do you consume per week?* This field is required.e.g., coffee, tea, energy drinks, soda, pre-workout
None
1-2
3-5
6-9
10 or more
21
Do you feel like you get enough sleep and wake up feeling rested each day?* This field is required.
YESNO
22
Do you smoke tobacco or use a vaporizer alternative?* This field is required.
YESNO
23
Do you use a fitness, activity or step tracker? If so, which one?* This field is required.e.g., FitBit, Apple Watch, Garmin
24
Is there anything else you'd like me to know before we get started?
Should be Empty: