Nutrition Coaching Intake Form
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Personal Information
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Weight:
Only if comfortable sharing :)
Height:
Email:
example@example.com
Occupation:
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Health Background
Do you have any diagnosed medical conditions or injuries I should know about?
Are you currently taking any medications or supplements?
Do you have any allergies or intolerances?
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Nutrition Background
What does a typical day of eating look like for you?
Do you follow any specific diets or avoid certain foods?
Vegetarian
Vegan
Gluten-free
Dairy Free
Low FODMAP
Keto
Other
If other, please specify below:
What’s your experience with food tracking?
Never tracked before
Calorie tracking (e.g. MyFitnessPal)
Macro tracking
Food diary (noting meals/snacks)
Tracking affected my mindset negatively
I no longer track
Have you dieted before? What have you tried and how did it go?
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Relationship With Food
This section looks at how you think and feel about food, and the habits or patterns that shape your eating.
How would you describe your current relationship with food?
Do you struggle with any of the following?
Skipping meals
Binge eating
Guilt around food
Fear of certain foods
Emotional eating
Restriction/rigid food rules
None of the above
Is there anything you'd like to feel better about when it comes to food?
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Lifestyle & Movement
What’s your current training or movement routine (if any)?
Share what your training currently looks like and how challenging each session feels. e.g light, moderate, or hard.
Do you feel like your current nutrition supports your energy and recovery?
Yes
Sometimes
No
Not sure
How many hours do you sleep per night?
How would you rate your sleep quality?
Poor
Fair
Good
Excellent
What are your current stress levels?
Low
Moderate
High
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Goals & Support
What do you want help with the most?
e.g. improving energy levels, building consistency, fat loss, fuelling training etc.
Why is this important to you right now?
How do you prefer to check in with me?
Weekly check-in form
Text
Call/video call
In person
Is there anything else you'd like me to know so I can best support you? 💙
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