Sign Up Form

Name*

First NameLast Name

Today's date*

MonthDayYear

Email*

Phone Number*

Macro Nutritional Coaching includes: Individual macro assessment | Custom meal creations | Visual grocery list | Weekly follow-ups & adjustments | Text & phone call communication. This is a month-to-month relationship, there are no contractual obligations.

All clients have access to my personal cell.

How did you hear about my nutrition coaching?*

What is your desired goal?*

Occupation*

Age*

Height*

Current weight*

Goal weight*

Body Fat % (If measured by a Professional: DexaBody, Bod Pod, etc.)

What time do you wake up & go to bed?*

What time do you eat your first & last meals?*

Do you workout at home, a gym or both?

Cardio and/or Group Fitness frequency. Days per week, minutes per day and effort level. *

Weight lifting frequency. Days per week, minutes per day and effort level.*

Any injuries (past or present) that could affect your training or nutrition? If yes, please explain:*

Any dietary restrictions or food allergies? If yes, please explain:*

What medications do you currently take?*

Which supplements and brands do you currently take? Protein powder, BCAA's, preworkout, etc.*

Please provide a 2-day food journal with as much information as possible (time of eating, meal items, portion size, etc.)*

Which Grocery Stores do you shop at? Example: Costco, Walmart, Kroger/Fry's, Target, etc.*

List all of your favorite Proteins. Protein Examples: Chicken, ground beef, non meat proteins, yogurt, etc.*

List all of your favorite Carbohydrates. Carbohydrate Examples: Rice, cereal, potatoes, waffles, bread, etc.*

List all of your favorite Fats. Fat Examples: Hummus, avocado, butter, cooking oil, salad dressings, etc.*

List all of your favorite Fruits. Fruit Examples: Strawberries, bananas, dry fruit, canned fruit, etc.*

List all of your favorite Vegetables. Vegetable Examples: Green beans, spinach, canned veggies, etc.*

List all of your favorite Condiments & Milks. Condiment & Milk Examples: Ketchup, alfredo sauce, honey mustard, almond milk, coffee creamer, etc.*

List all of your favorite sweets, treats & cheats. Examples: Takeout food, ice cream, candy, etc.*

All meals are designed in the MyFitnessPal App (a free food tracking website). You will need a MyFitnessPal account to participate in my coaching program. Please share your username & password.*

A visual itemized grocery list will be available to you via Google Drive. To access your visual grocery list, please share the email associated with your Google Drive account*

Please note any questions or concerns you may have here before submitting your client questionnaire.*