Nutrition and Fitness Intake Form
Please take a few minutes to complete this form thoughtfully. This is what allows me to personalize your nutrition and fitness plans and create a strategy tailored specifically to your body, your lifestyle, and your goals.The more honest and detailed you are, the more powerful your session will be. 💖👉 This will take approximately 15 - 20 minutes.
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Name
First Name
Last Name
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Email
example@example.com
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How old are you?
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What menopause symptoms have you experienced so far and how have they impacted your quality of life? Menopause symptoms can include: weight gain, sleep disturbances, hot flashes, brain fog, joint pain, increased anxiety, burnout, fatigue, etc.
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Please share any health conditions, past surgeries or medical treatments, injuries, medications, dietary restrictions, or physical limitations that may be important for me to know when creating your personalized nutrition and strength-training plan. Please include any symptoms you may be currently experiencing, any activities you have been advised to avoid or modify, and anything else you believe I should know in order to create a safe and appropriate plan for you.
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What's your #1 HEALTH or BODY GOAL? Why do you want to achieve this result?
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What would you love to achieve in the next 6 months?
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What would your dream outcome look like in the next 12 months?
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What have you tried in the past when it comes to nutrition, fitness, or weight loss?
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What do you feel is currently not working for you right now?
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What do you believe is the biggest obstacle holding you back right now?
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What is your current weight (kg)?
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What is your desired/optimal weight (kg) ?
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What is your height (cm)?
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What is you activity level at the moment?
Sedentary (little to no exercise)
Lightly Active (1 to 3 days of exercise per week)
Moderately Active (3-5 days of exercise per week)
Very Active (6-7 days of exercise per week)
Extremely Active (7 days very hard exercise)
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Tell me about your work/career: What do you do?
How would you describe your schedule?
I work standard hours
I work long hours
I work evenings/weekends
I travel frequently
Other
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Tell me about your family and home life (including any additional stressors such as caregiving for aging parents for example)
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Walk me through a typical day of eating (no judgment—just honesty)
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Do you currently make a conscious effort to include protein-rich foods in your meals? If so, what are your main protein sources?
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Have you ever tracked your food intake, calories, or macronutrients (protein, carbohydrates, and fats)? If so, what was your experience like?
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If you are currently exercising, what does your routine look like?
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Have you ever done strength training ?
No, never
When I was younger
I have some dumbbells and I have done some YouTube videos here and there but I'm not following a structured program yet
I strength train with progressive overload 2-6 times a week at home and/or the gym
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Do you currently have any injuries, joint issues or other conditions that may be preventing you from exercising including lifting weights ?
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Where would you prefer to exercise (at home or at a gym), and what equipment do you currently have access to (dumbbells, resistance bands, weight machines, etc.)?
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How committed are you to making changes right now?
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Why is this important to you at this stage of your life?
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Is there anything else you’d like me to know before our Game Plan/Onboarding Call ?
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