Clone of 1 Hour Macro Consultation Questionnaire w/payment

Hormone-Smart Nutrition Plan Intake Form

Thank you for booking your Hormone-Smart Nutrition Plan! Please complete these questions with as much detail as possible. After you submit this questionnaire, we'll schedule your 1-hour personalized consultation. During our consultation, we'll dive into your hormone symptoms, nutrition patterns, health history, and goals - so I can create a nutrition plan that actually works for this stage of life. Within 48 business hours after our call, you'll receive your custom implementation guide including: your personalized nutrition targets, hormone-supportive nutrition recommendations, food lists and meal ideas, tracking tutorials and planning tips. Plus, you'll have 2 weeks of email support to help you implement everything we discuss. I look forward to speaking with you!
Personal Information
Name*
Email*
Phone Number
Gender*
Preferred Pronouns*
he/him, she/her, they/them
Age*
Height (inches)*
Weight (lbs)*
What is your occupation?*
Do you have any current injuries or medical conditions?*
HORMONE & LIFE STAGE
Are you currently in perimenopause, menopause, or postmenopause?*
Are you currently on Hormone Replacement Therapy (HRT)/Bioidentical HRT?*

YesNo
If yes, what type of HRT are you on?
What are your TOP THREE symptoms right now?*

Weight gain (especially around midsection)Fatigue/low energyBrain fogMood swings/irritabilityHot flashes/night sweatsSleep issuesCravings (sugar, carbs, salt)BloatingLoss of muscle massJoint pain/stiffnessAnxietyDepressionOther
How long have you been experiencing these symptoms?*
Goals and Challenges
What are your health and wellness goals?*

Lose weight/inchesIncrease muscle massLifestyle changeCreate healthy food choices
Think about your ideal future self in 2 years. How do you feel? What do your days look like? What do you look like? What's important to you? *
What is your biggest nutritional challenge?*

Dislike cooking or don't know how to cookDon't know what I should eatWine/alcoholTime to prepare mealsLarge portionsEating out frequentlySweet toothEating quicklySnacking when not hungryCravingsLack of planningEmotional/stress eatingFamily or peer pressureOther
Activity
How many hours do you sit during the day?*
How many steps do you take per day?*

0-4,0004,000-6,0006,000-8,0008,000-10,00010,000 +Not sure
How many hours of cardio do you complete per week? What type of cardio?*
How many hours of strength training do you complete per week? What type of strength training?*
Nutrition and Routine
Have you tracked your food or macros before?*
If you currently track your macros or calories, what are your current macro or calorie targets?*
Are you a vegetarian or vegan?*
Do you have any food intolerances, allergies, or special preferences?*
Do you skip meals? If yes, which ones?*

BreakfastLunchDinnerI don't skip meals
How often do you feel "hangry" (shaky, irritable, or anxious when hungry)?*
Do you experience afternoon energy crashes?*
On a scale of 1-10, how would you rate your current energy levels?*
(1 = completely exhausted, 10 = fully energized)
Please describe your current nutrition regimen. Be brutally honest with what you're doing currently - not where you hope to be. No judgement here!*
What tactics have you tried in the past to improve your nutrition? What has worked? What didn't?*
Have you dieted for weight loss in the last 2 years? If yes, what diets? How many calories were you eating? How long did that last? Please be as detailed as possible.*
Have you ever been diagnosed with an eating disorder or struggled with an undiagnosed eating disorder?*
Do you currently:*

Meal PrepMeal PlanUse Meal Prep ServiceWing it
Describe your meal prep and/or meal planning:*
How many time a week do you drink alcohol?*

0-11-22-34 +I don't drink alcohol
Stress Management
Do you have daily or weekly self-time dedicated to just you?*

YesNo
What things in your life make you happy? What activities charge your battery?*
On a scale of 1-10, how stressed do you feel on a typical day?*
(1 = completely calm, 10 = overwhelmed)
WHAT YOU'RE HOPING TO LEARN
What do you most want to understand from this consultation?*

How to eat for my changing hormonesHow to stop cravingsHow to have steady energy all dayHow to lose weight without restrictingHow macros work and how to track themHow to balance blood sugarHow to eat out without derailing progressWhat foods support my hormones bestOther
Let's Go!
What do you hope to leave this consultation with?*
Is there anything else you would like me to know? What specific questions do you have for me?*

My Products

Cindi StickleA 1:1 laser-focused Nutrition Consultation for women 40+ navigating the metabolic and hormonal shifts of perimenopause and menopause

$247.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Hormone-Smart Nutrition Plan Intake Form

Personal Information

HORMONE & LIFE STAGE

Goals and Challenges

Activity

Nutrition and Routine

Stress Management

WHAT YOU'RE HOPING TO LEARN

Let's Go!