Nutrition Coaching Intake Form

  • Nutrition Coaching Intake Form

  • Personal Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Appointment

  • Health Status

  • What are your fitness or nutrition goals?*
  • Rows

  • Health Status

  • Do you smoke?
  • Do you drink alcohol?
  • Do you have any dietary restrictions?
  • Are you pregnant? (women)
  • Do you go to the gym and/or exercise?

  • Acknowledgment

  • I hereby certify that all information about my health conditions and nutrition are accurate and true to the best of my knowledge.

    I understand that I am responsible for consulting my physician or health care provider about this nutrition consultation.

    I release this institution and its employees from any liabilities, claims, and demands that may arise during this consultation. 

  • Date Signed
     - -
  • Should be Empty: