Nutrition Questionnaire

Step 1: Nutrition Questionnaire

Please fill out this form as completely and accurately as possible. This information is critical to help you receive maximum benefit from the program.
Personal Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Gender
Age
Height (in inches)
Weight (in pounds)
Medical History and Nutrition Questionnaire
Please indicate whether you have been diagnosed with any of the following diseases or symptoms

Other
Provide further information if any
Do you have a family history of any metabolic conditions (heart attack, stroke, diabetes, hypertension, thyroid issues, hormone issues, etc.):
How many hours of sleep do you get per night?
Do you wake up feeling "well rested"?
Do you currently implement any sleep hygiene strategies, over the counter medications/supplements and/or prescription medications to help you sleep? If so, please list them and describe your evening routine:
Please list any injuries and/or surgeries and dates they occurred please include any type of cancer diagnosis/treatment/removal):
Do you take any medications? If yes, list below with name, dosage, & time taken:
Do you take any supplements or vitamins? If yes, list below with name, dosage & time taken:
What does your alcohol intake look like (drinks per day or week & drink preferences):
What does your caffeine intake look like (oz or cups per day & drink preferences):
Do you use any nicotine (how much & what methods):
What does your water/fluid intake look like (oz or cups per day & drink preferences):
Do you have any food allergies, sensitivities, or intolerances? If yes, list below:
Do you have any foods that you dislike &/or would rather never eat again? If yes, list below:
Describe your current typical eating schedule/routine (meals, snacks, hydration examples & times of day):
How often do you skip meals?
Please select the physical activities you participate in:

Other
Describe your current activity routine (competition, practice, training, movement schedule):
What are your main complaints, issues, ailments (brain fog, bloating, fatigue, GI discomfort, irritability, low libido)?
What are your 6-8 week goals/desired outcomes? What are you 6-12 month goals/desired outcomes?
Our Terms and Conditions
One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Do you have any initial questions?
After you click Submit, you'll be redirected to the Membership Page where you can complete submitting your additional information and schedule your initial consultation.
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Step 1: Nutrition Questionnaire

Personal Information

Medical History and Nutrition Questionnaire

Our Terms and Conditions

After you click Submit, you'll be redirected to the Membership Page where you can complete submitting your additional information and schedule your initial consultation.