Meal Plan Intake

1

How old are you?

2

Do any of these apply to you right now?

Type 1 diabetes, or type 2 managed with insulin

Kidney disease or dialysis

Active cancer treatment

Liver disease

Heart failure

Bariatric or any GI surgery in the past year

A digestive condition currently flaring (Crohn's, colitis, gastroparesis)

Difficulty swallowing, or I use a feeding tube

Severe allergies to 4 or more foods

A rare metabolic or genetic condition affecting what I can eat

None of these

3

Are you currently pregnant, trying to conceive, or breastfeeding?

Pregnant

Trying to conceive

Breastfeeding

None of these

4

Have you had any of these in the past 3 months?

Blood in your stool, or black or tarry stool

Weight loss you can't explain

Vomiting that keeps happening

Pain or trouble swallowing

Fainting or repeated dizziness

Waking at night from stomach symptoms

None of these

5

Do any of these describe you?

I've been diagnosed with or treated for an eating disorder

I make myself vomit, or use laxatives, diuretics, or diet pills to control my weight

I often feel out of control around food

I've wondered whether my relationship with food or my body is a problem

None of these

6

Do you train/exercise 10+ hours a week while also limiting how much you eat?

Yes

No

I train a lot but I don't limit my intake

I don't train or exercise that much

7

Full name

First Name

Last Name

8

What should I call you?

9

Pronouns

10

City and State

11

Gender

Woman

Man

Non-binary

Prefer not to say

12

What's your birth sex?

Female

Male

13

Do you currently menstruate?

Yes, regularly

Yes, irregularly

No — menopause or perimenopause

No — hormonal contraception, hormone therapy, hysterectomy, or another reason

Not applicable

Prefer not to say

14

Height (inches)

15

Current weight (lbs)

18

If the plan only fixed one of those, which matters most?

19

What's your biggest obstacle?

I don't know what to eat

No time to plan or cook

I get bored and quit

Good during the week, falls apart on weekends

I eat well but don't see results

I eat emotionally

My schedule is unpredictable

Cooking for others with different needs

Something else

20

What made previous plans stop working for you?

23

Any other allergy or intolerance not listed, and what happens when you eat it?

24

Has any allergy ever caused a severe reaction needing epinephrine?

Yes

No

Not applicable

25

All prescription medications you take, with doses if you know them. Write "none" if none.

27

If you take a GLP-1 medication: How much are you eating compared to before starting?

About the same

Somewhat less

Much less

Very little, I have to remind myself to eat

28

Have you had bloodwork in the past 12 months?

Yes, and I'll upload it

Yes, but I don't have a copy

No

Not sure

29

Upload your labs — PDF, screenshot, or photo. Multiple files welcome.

Drag and drop files here

Select files to upload

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30

Has a provider flagged anything in your bloodwork, or said they wanted to recheck something?

31

What time do you usually eat your first food of the day?

32

What time do you usually eat your last food of the day?

34

How often do you eat food you didn't prepare — restaurant, takeout, delivery, cafeteria?

Rarely

1–2×/week

3–4×/week

5–6×/week

Daily or more

35

Current activity level

Mostly sedentary

Lightly active

Moderately active (3–4×/wk)

Very active (5–6×/wk)

Extremely active or physical job

36

Do you do resistance or strength training?

Yes, 2+ times a week

Occasionally

No, but I'd like to

No, not interested

37

What time of day do you usually work out?

38

Hours of sleep on a typical night

39

Do you work a shift, overnight, or rotating schedule?

No, standard daytime

Yes, evenings

Yes, overnight

Yes, rotating

Unpredictable

42

How many meals per day should the plan include?

2

3

4

5+ small meals

44

Same breakfast most days?

Ideal — one less decision

Fine with 2 options

I want 3–4 options

Different most days

45

Same lunch most days?

Same daily is fine

2 options

3–4 options

Different most days

46

And dinner?

Same weekly rotation is fine

3–4 options

5–7 options

Real variety, different most nights

47

How do you feel about leftovers?

Love them, cook once eat twice

Fine with them

Only for lunch, not dinner

Not more than a day later

I won't eat leftovers

48

Are there meals you already eat regularly and would happily keep? I'd rather build around what's working than replace it.

53

How should portions be expressed?

Cups and tablespoons

Grams and ounces

Hand and palm portions

Plate proportions

61

Foods you absolutely will not eat, no matter how healthy. List them all — I won't be offended. Include any textures you can't handle (slimy, mushy, chewy, gritty).

62

Your favorite meals in the world, or the ones you'd never want to give up.

66

How many meals a week should the plan cover?

All of them

Weekdays only

67

Where do you eat out most often? Name the actual places — chains, local spots, etc.

68

How should the plan handle treats and dessert?

Build in a daily small treat

A few a week

Weekends only

Leave them out

Give me strategies instead of scheduled treats

74

Any staples you always keep on hand that I should build around?

75

Do you take any supplements? If not, are you interested in supplements?

Yes, I currently take supplements

Yes, I'm open to supplementation

No, I'm not interested in taking supplements

76

List everything you currently take — vitamins, minerals, herbs, protein powder, greens powders. Doses and brands if you know them.

78

Any supplement you've reacted badly to, or refuse to take?

79

Do you want calories and macros shown?

Show me everything

Macros but not calories

Calories but not macros

No numbers, just tell me what to eat

80

Anything else you want me to know before I build this?

81

Please confirm you understand:

This is nutrition guidance and does not replace medical care

Alexandra Palumbo, RD is not diagnosing or treating any condition

Supplement recommendations are suggestions and I'm responsible for clearing them with my prescriber

I'll report changes to my medications, diagnoses, or health

I'll contact a medical provider if I have concerning symptoms

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I've answered accurately

82

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83

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