Name
*
First Name
Last Name
Email
*
example@example.com
Phone number
*
-
Country Code
Phone Number
Instagram handle
Preferred mode of contact
*
Email
Whatsapp
Telegram
Health and medical history
Gender
*
Male
Female
Other
Date of birth
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Height (cm)
Weight (kg)
Body fat (%) (If known)
Are you getting a regular period?
*
No, I am (peri-)menopausal
No, but I should be
Yes
Do you have a family history of any of the following? Select all that apply.
Heart disease
High cholesterol
Cancer
Diabetes
High/low blood pressure
Others
Do you have any other medical conditions / issues I may need to be aware of? If yes, please describe and detail the type of treatment / medication you are receiving for it.
*
Lifestyle
Do you smoke and how often?
Not at all
About once a month or less
About once every 2 weeks
About once a week
More than once a week
Daily
Do you drink and how often?
*
Not at all
About once a month or less
About once every 2 weeks
About once a week
More than once a week
Daily
Do you have any allergies? If yes, please specify.
*
Are you currently on a special diet either by personal choice or prescribed? If yes, please specify.
What are some foods you love?
What are some foods you hate?
Are you following any type of diet or nutrition guidelines at the moment? State your calorie and macronutrient intake if known.
*
Are you taking any supplements (hormonal, sports, vitamin, mineral, etc) at the moment? If yes, please specify.
*
Are you regularly active in sports and / or exercise?
No
Yes
Describe the sports/exercise/training you currently do. Duration, number of days, how your typical training weeks and blocks are set up.
*
What is the frequency and duration of your training/activity?
*
What other types of movement and / or activities do you do apart from sports / exercise? Duration, number of days etc. State your daily step count if known.
*
On average, how many uninterrupted hours of sleep do you get per night?
*
Considering all aspects of your life, what is your typical stress level on an average day?
*
No Stress
1
2
3
4
5
6
7
8
9
Extreme Stress
10
1 is No Stress, 10 is Extreme Stress
Right now, how much do the people and things around you support your health and fitness goals?
Not At All
1
2
3
4
5
6
7
8
9
Completely
10
1 is Not At All, 10 is Completely
Who decides on most of the menus / meal types in your household? Select all that apply.
Me
Spouse/partner
Roommate(s)
Child(ren)
Domestic helper
Parents
Other
Who does most of the cooking in your household? Select all that apply.
Me
Spouse/partner
Roommate(s)
Child(ren)
Domestic helper
Parents
Other
Do you currently have or have you recently had any of the following? Select all that apply.
Diabetes
Arthritis
Rheumatic fever
Frequent headaches
Epilepsy
Asthma
Shortness of breath
Frequent cough
Chest tightness
Frequent headaches or migraines
Dizziness/faint spells
High/low blood pressure
High cholesterol
Heart disease
Heart palpitations/murmur
Heart surgery
Stroke
Cardiac arrhythmia
Angina
IBS
Gastritis
Other
So, why are you here?
What are your goals for nutrition coaching? How would you like your habits, health and fitness, eating, and / or your body to be different? Be specific and provide time frames if you have them.
*
What are your main challenges in reaching these goals on your own?
*
What have you tried to do in the past to achieve these goals? What worked and what didn't work?
*
Are you ready to commit to the changes it will take to get you to your goals?
*
Yes, of course
No, not right now
Not sure
What are your goals? Select all that apply.
Lose weight/fat
Gain weight
Maintain weight
Add muscle
Improve overall health
Get stronger
Improve physical fitness
Look better
Feel better
Have more energy
Healthy aging
Gain control of eating habits
Physique competition
Improve athletic performance
Get off or decrease medication
Other
You're all done! Hit submit to send in your application. I'll be in touch as soon as I can via your preferred mode of contact.
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