One-Time Nutrition Consultation

One-Time Nutrition Consultation

Detailed Questionnaire
Full Name*

First NameLast Name
Best email to reach you*
MaleFemaleOther
Age*
years
Height*
inches
Current weight*
lbs
Overall goals: Please include any specific goals for your training and/or body composition: *
NUTRITION
YesNo
If so, please provide the last set of macros you used, and a little history on your success/failures with macros
What is a typical breakfast?
NeverRarelyOccasionallyAlways
How many caffeinated beverages do you consume a day?
How many times a week do consume alcohol?
YesNo
If so, please state which ones
On average, how much water do you drink a day?
List any food allergies/intolerances
SLEEP
On average, how many hours of sleep do you get a night?
NeverRarelySometimesOftenVery often
What time do you usually go to sleep?
Very poorPoorAverageGoodVery Good
Very poorPoorAverageGoodVery good
Very poorPoorAverageGoodVery good
STRESS
On a scale of 1-10 what would you rate your general level of anxiety/stress?
Not stressfulSlightly stressfulStressfulVery stressful
Are there any other things that cause you notable stress?
YesNo
By checking this box, I confirm that I am NOT suffering from an active eating disorder. WIP coaches cannot treat eating disorders. If you have any questions, please contact gabby@wipnutrition.ca
EXERCISE
none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
How many times a week do you exercise/move with some intensity?*
Which kind(s) of exercise/movement do you do and for how long?*
GENERAL HEALTH
YesNo
First trimester (1-13 weeks)Second trimester (14-27 weeks)Third trimester (28- 40+ weeks)N/A
If you are currently breastfeeding, please provide further details (i.e are you exclusively breastfeeding? How is your milk supply? Are you on a dairy/soy-free diet? How many more months do you plan on continuing to breastfeed?)
YesNo
If you have any injuries, please list them.
Do you have any current diagnosed medical conditions? If so, please list them.
If you are on any medications, please list them.
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WIP Nutrition Coaching
Thank you for completing the questionnaire! Once payment is submitted, I will prepare your personalized nutrition plan within 24-36 hours. It will be sent to the email you provided.

$250.00 Quantity

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One-Time Nutrition Consultation

NUTRITION

SLEEP

STRESS

EXERCISE

GENERAL HEALTH