Meal Planning Questionnaire

Justin Check, NSCA-CPT, NESTA-FNC, NASM-CES, TPI Lv 1 Check Total Health, LLC 239.209.7878 Justin@check-yourself.com www.check-yourself.com
Disclaimer: We are not medical health practitioners or mental health providers and we do not consider ourselves to be in any capacity. Rather, we serve as coaches, mentors and guides who help you reach your own health and wellness goals. The information we provide is based on our personal experience, studies of fitness and exercise and our experience as Personal Trainers. While we draw on our prior professional expertise and background in many areas, you acknowledge that we are supporting you in our roles exclusively as fitness coaches only. We provide information concerning, but not limited to, exercise and fitness nutrition. The information provided regarding nutrition and exercise is not intended to be a substitute for professional medical advice, diagnosis or treatment. Never disregard professional medical advice, or delay in seeking it, because of something you have read or heard from Check Total Health. Never rely on nutrition or exercise information in place of seeking professional medical advice.
Participant Acknowledges Disclaimer Above*
Initials
*Please answer each question as detailed as possible:
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name*
Age*
Gender*

MaleFemale
Current Weight*
Approximately how long have you been this weight?*
Goal Weight (if any)
Height*
Waistline Measurement: *Do not suck in your abdomen. Relax and stand in a natural upright position when measuring. Males measure tightly around the navel. Females measure tightly 1 inch above the navel**
Planned Weekly Exercise/Activity Level (be as specific as possible- type and duration of physical activity/exercise)*
Time of day you will typically wake up and go to bed at? *
Do you eat breakfast and at what time?*
What time do you typically workout?*
Time of day you typically eat dinner (or last meal)?*
How many times a week do you drink alcohol and # of drinks do you typically have?*
How many meals do you EAT OUT per week typically?
Breakfasts*
Lunches*
Dinners*
How many meals do you PREAPARE AT HOME each day? (please give as much detail as possible)*
How many meals per day do you typically eat?*
How many meals per day can you feasibly eat (5-6 is recommended)*
Do you have any food allergies or intolerances? If yes, please describe in the box below. If no, please answer "No"*
What are your current eating habits? Give me an example of a typical day of everything you would normally eat and drink (the good and the bad; be specific with food items, quantities, and times)*
Please list all habits you believe are negatively impacting your weight/body composition the most.*
Would you be open to a meal prep/delivery service?*

YesNo
Anything else I should know/consider about your eating habits or food preferences when building your meal plan? Please list all supplements you use energy, recovery, weight-loss, performance, etc.
Please mark all food items below that you like to eat in each of the lists provided (Lean Proteins, Complex Carbohydrates, & Fats. Be sure to write down any additional food items notlisted that you would like to incorporate in your meal plan in the “others”food item field in each category.
Lean Proteins

Tofu or Soybean Meat SubstitutesProtein Bar/Powder/Drink (any variety)Whole EggsEgg WhitesSkim/Low-Fat MilkChickenTurkey BreastTurkey/Breakfast SausageLean PorkLean BeefWild Game (elk, bison, venison, etc.)White Fish (any variety)Canned/Pack TunaSalmonShrimp or ScallopsGreek Yogurt Low fatLight Cheese SticksCottage or Ricotta CheeseOther
Complex Carbohydrates

Whole Grains (rice, quinoa, couscous, pasta, etc.)Cream of Rice/Wheat/GritsHigh-fiber Cereal/GranolaOatsBean/Soy-Based PastasRice CakesSweet PotatoWhite Potato (any variety)Legumes/Beans/Lentils (any variety)High-fiber Breads or WrapsMixed Berries (any variety)All-natural, low-sugar jam/fruit preserveFresh Fruit (any variety)Fruit & Grain Bars/Breakfast BarsCoconut SugarAgave NectarOther
Fats

All-natural Nut Butter (any variety)Whole Eggs/YolkPlant-based Butter (any variety)Nuts (any variety)Cheese (any variety)Olive oilCoconut oilAvocado/GuacamoleOther
Other Foods: Please list any other foods (regardless of macro composition) that you would like to see included in your meal plan, including all pre-made/store bought items you currently like to eat.
In order for your meal planning process to begin, payment must be completed. If you choose to submit this form without payment, please Zelle (239-209-7878) at your earliest convenience. Please select the duration of coaching you'd like to commit to:
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8 Weeks: Custom Meal Plan & Nutrition Coaching includes 3.5% convenience fee
$414.00 Quantity



12 Weeks: Custom Meal Plan & Nutrition Coaching includes 3.5% convenience fee
$518.00 Quantity



16 Weeks: Custom Meal Plan & Nutrition Coaching includes 3.5% convenience fee
$621.00 Quantity



Total

$0.00
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*Please answer each question as detailed as possible:

Please mark all food items below that you like to eat in each of the lists provided (Lean Proteins, Complex Carbohydrates, & Fats. Be sure to write down any additional food items notlisted that you would like to incorporate in your meal plan in the “others”food item field in each category.