One-Time Nutrition Consultation
Detailed Questionnaire
Full Name
*
First Name
Last Name
Best email to reach you
*
Gender
*
Male
Female
Other
Age
*
years
Height
*
inches
Current weight
*
lbs
Overall goals: Please include any specific goals for your training and/or body composition:
*
NUTRITION
Are you familiar with counting macros?
*
Yes
No
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?
Do you eat lots of greens on a daily basis?
Never
Rarely
Occasionally
Always
How many caffeinated beverages do you consume a day?
How many times a week do consume alcohol?
Do you take any supplements?
Yes
No
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?
Do you have issues staying asleep through the night?
Never
Rarely
Sometimes
Often
Very often
What time do you usually go to sleep?
How would you rate your sleep quality?
Very poor
Poor
Average
Good
Very Good
How would you rate your energy levels when you wake up in the mornings?
Very poor
Poor
Average
Good
Very good
How would you rate your energy levels throughout the day?
Very poor
Poor
Average
Good
Very good
STRESS
On a scale of 1-10 what would you rate your general level of anxiety/stress?
How stressful do you consider your job?
Not stressful
Slightly stressful
Stressful
Very stressful
Are there any other things that cause you notable stress?
Do you feel you sometimes turn to food to conceal your emotions?
Yes
No
IMPORTANT
*
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
Whats the activity level at your job?
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
Are you currently pregnant or breastfeeding?
*
Yes
No
If you are currently pregnant, which trimester are you in?
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?)
Are you a current cigarette smoker?
Yes
No
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.
Please rate your readiness for change
*
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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.
$
125.00
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