Metabolic Audit + Action Plan

Metabolic Audit + Action Plan

INTAKE FORM
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Age*
Height*
Example: 5'5"
Current Weight (lbs)*
Goal Weight(if applicable)
What are your primary goals: (Select all that apply)*

Fat lossImprove energyReduce bloating/ inflammationBalance blood sugarBuild strengthImprove digestionImprove sleepHormonal balanceConfidence with foodOther
In one sentence, what would feel like success in the next 30 days?*
How many meals do you typically eat per day?*

1-234+Varies
Do you currently track food?*

YesNoUsed to, but not currently
How would you describe your current eating pattern?*
Dietary preferences or restrictions (select all that apply)*

Gluten-freeDairy-freeVegetarianVeganNoneOther
Any known food sensitivities?
How would you rate your daily energy?*

Very lowLowModerateGoodExcellent
When do you feel most fatigued?*

MorningAfternoonEveningVaries
Do you experience cravings?*

RarelySometimesOftenDaily
If yes, when and what type of cravings?
How often do you currently exercise?*

0-1x/ week2-3x/ week4-5x/ weekDaily
Where do you train?*

HomeGymBothNot currently training
What type of exercise do you do most?*

Strength trainingCardioClassesWalkingMixedNone
Any injuries or limitations I should know about?*
How would you rate your current stress level?*

LowModerateHighVery high
How many hours of sleep do you get on average?*

<55-66-77-88+
Do you wake feeling refreshed?*

YesSometimesRarely
Biggest stressors in your life right now?*
Are you currently pregnant or breastfeeding?*
Do you have any diagnosed conditions?*

Thyroid disorderPCOSInsulin resistance/ PrediabetesAutoimmune conditionDigestive issuesNoneOther
Are you taking any medications? Please list*
Are you currently taking supplements? Please list*
How ready do you feel to make consistent changes? (Scale 1-10)*
1-10
What has NOT worked for you in the past?*
What kind of support feels most helpful right now?*

Clear structureAccountabilityEducationSimplicityEncouragementAll of the above
Why do you feel drawn to this session right now?*
Is there anything else you want me to know before our call?*
If nothing changed in the next 6 months, how would that feel?*
Consent & Agreement
Your Informed Consent (Checking all boxes is required to move forward and ensures we are aligned for your coaching experience)*

I understand this session provides educational guidance and does not replace medical careI understand results vary based on consistency and individual factorsI agree to communicate openly and honestly
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Metabolic Audit + Action Plan

Consent & Agreement