Nutritional Assessment Questionnaire Form

1
Full Name:
First Name
Last Name
2
Email
example@example.com
3
Age:
4
What type of coaching are you interested in?
Fat loss thru deficit
Reverse Dieting (metabolism repair if have been chronic low cal)
Reverse Dieting to maintenance after short term deficit
Muscle building thru surplus
Other
5
Sex:
Male
Female
6
Current weight
7
Height
8
Goals
Muscle Building
Weight Loss and Fat Loss
Strength Building
Lifestyle Change
Healthy Food habits
Metabolism Repair
9
How many cardio sessions each week?
10
How many minutes of cardio per session?
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Type of Cardio
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Current weight lifting regimen:
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Ok
Ok
13
Do you know how many steps per day you get on average?
14
Current nutrition regimen:
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Ok
15
Food Allergies?
16
Vegetarian or Plant based?
17
Current supplementation if applicable:
18
Dieting/coaching history?
19
How often have you dieted for weight/fat loss over the last 5 years?
20
Have you tracked macros or calories? If so, what were past goals? Please specify timelines on how long doing numbers and if currently following them?
21
What does your daily schedule look like? (work, school, gym, etc)
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Ok
22
Any medical history that could affect your physique goals? Hypothyroidism? Hormonal imbalances? Diabetes? PCOS? Pregnant? Nursing?
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Ok
23
Are you ready to financially invest in coaching for a minimum of 12 weeks? Are you willing to work with my assistant coach?
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Shannon Collins is not a physician or registered dietician. Please consult with your physician for medical clearance and approval before starting this nutrition program. Information provided here will be in suggestion use only. It is not intended to diagnose, treat, cure, or prevent any health related problem-nor is it intended to replace the advice of your physician. Must be at least 18yrs old to apply. Please do not apply if you have a history of an eating disorder. By submitting this form you agree to all these terms.
Agree
25
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