Meal Planning Intake Form & Preferences Questionnaire
Name
First Name
Last Name
Email
example@example.com
Have you ever been clinically diagnosed with any of the following:
Diabetes (Type 1 or Type 2)
Heart disease
High blood pressure
High cholesterol
Thyroid conditions
PCOS
Gastrointestinal disorders
Eating disorders (past or present)
Are you currently Pregnant or breastfeeding
Any condition requiring medical supervision
Are you currently taking any medication? Have you consulted with a physician on how a dietary change may affect you under medication?
Please rate your readiness to change your eating habits:
Don't want to change
1
2
3
4
I'll change everything
5
1 is Don't want to change, 5 is I'll change everything
How would you describe your current eating habits? What changes feel doable right now, and what feels like too much to take on at the moment?
How many meals do you realistically eat most days? What times of day are hardest for eating well? (mornings, late nights, weekends, workdays)Who does most of the cooking and grocery shopping?
How often do you eat at home, On the go, At restaurants or takeout? Please give me a snap shot of a typical weekday and weekend.
What ingredients do you like to cook with? What are readily available in your home? Would you be open to recommendations?
How would you describe your cooking ability?
Minimal (quick/simple)
Comfortable with basics
Enjoy cooking
How much time can you realistically spend on: Meal prep per week? Cooking per meal?
Do you have access to:
Instapot
Stove/oven
Microwave
Air fryer
Slow cooker
What foods do you love and want included regularly?
What foods do you dislike or avoid?
Any food allergies or intolerance?
Are there any sauces, dressings, or seasonings you often use on your food? If so please list allow with brand. Example: Always using ketchup on burgers, ranch on salads, etc.
Are there foods you tend to overeat or struggle with control around? Why do you think that is?
What stores do you grocery shop at?
When are you usually most hungry during the day?
Do you prefer: Larger meals, Smaller, or more frequent meal? Do you snack? If yes, when and why? (hunger, stress, boredom)
How many days per week do you want to eat “on plan”?
How important is flexibility (social events, weekends, travel)? Can you elaborate?
How often How often do you currently consume alcohol, and approximately how much do you typically drink on those occasions?
I rarely drink (1–2 times per month or less)
1–2 days per week (1–2 drinks typically)
1–2 days per week (3–5+ drinks typically)
3–4 days per week (1–2 drinks typically)
3–4 days per week (3–5+ drinks typically
5–7 days per week (1–2 drinks typically)
5–7 days per week (3–5+ drinks typically)
My intake varies significantly week to week
I’m unsure / I don’t currently track it
Never
only socially
What sorts of things other than water or alcohol do you like to drink? Example: coffee 1/2 teaspoon honey and international delight creamer.
Do thinking keeping a daily food log where your responsible to taking a picture of everything you put in your mouth(that has calories), uploading it daily to the turnkey app, and having a coach review your log weekly would be helpful? Is that something you could commit to? Or would you need a less intense approach?
What’s your main nutrition focus right now?
Fat loss
Muscle gain
Improve performance and quality of life
Build health habits
Are you currently taking any supplements? Please list:
What’s one small change you feel confident you could maintain?
What feels like the biggest challenge with nutrition right now?
Do you feel ready to implement all the necessary changes now, or would a structured, gradual approach feel more manageable?
What best describes your weekly workouts?
Very Light: Almost no purposeful exercise.
Light: 1-3 hours of gentle to moderate exercise.
Moderate: 3-4 hours of moderate exercise.
Intense: 4-6 hours of moderate to strenuous exercise.
Very Intense: 7+ hours of strenuous exercise.
Describe your daily activity level
Very light: Sitting most of the day (example: desk job).
Light: mix of sitting, standing, and light activity (example: teacher).
Moderate: Type Continuous gentle to moderate activity (example: restaurant server)
Heavy: Strenuous activity throughout the day (example: construction work).
"Have you ever successfully lost weight before? If so, what were you doing and what caused the weight to come back?"
Current weight:
Goal weight
Do you have a timeline for your goal?
Height
Biological gender
Age
I understand that nutrition guidance provided is for general education and healthy lifestyle support only and is not medical nutrition therapy. I acknowledge that I am not receiving diagnosis, treatment, or advice for any medical condition. Please type yes if you understand.
Please confirm agreement with each statement before receiving coaching or meal planning:
The information provided is accurate
Client will communicate changes in health status
Client understands results may vary
I voluntarily agree to receive general nutrition guidance and understand that results are not guaranteed. I assume full responsibility for my choices and actions.
Are you looking for:
Structured meals
Food options/ templates
Simple guidelines
Accountability
All the above
Are there any nutritional concepts you’d like to be educated on?
Importance of protein and fiber
Food quality over quantity
Keto/low carb
Calories in versus calories out
The importance of resistance training in fat loss
Sustainability versus strictness
Meal timing
Fasting
Gut health
Sugar and carbs effect on the body
Other
Do you ever feel guilty after eating certain foods?
Never
Rarely
Sometime
Often
Almost Always
Do you ever feel out of control around food?
Sometime
Often
Almost Always
Rarely
Never
Have you ever intentionally restricted food intake to "make up" for overeating?
yes
no
Describe any patterns of overeating, binge eating, or restriction that you've experienced.
Have you ever skipped meals to compensate for eating more than planned?
Yes
no
What foods(if any) are most likely to make you feel guilty after eating them?
Have you ever felt like you "blew your diet" after eating a certain food? If yes, explain.
Are there foods you avoid because you believe they will automatically cause weight gain? Which foods make you feel nervous, out of control, or anxious to eat?
Which emotions are most likely to influence you're eating habits?
anger
anxiety
boredom
loneliness
stress
fatigue
celebration
Other
If or when you overeat what is happening before?
What situations most commonly lead to eating when you are not physically hungry?What time of day do you struggle most with food choices?
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