Nutrition PROGRAM FORM

PERSONAL INFORMATION

First name

Last name

Phone

Age

Height

Current Weight

Goal Weight (if any)

How many meals a day do you currently eat (including snacks)?

Do you tend to eat at consistent times each day?

Yes

Do you often skip meals? If yes, which ones?

How active are you in your everyday life? (e.g., walking, childcare, errands, stairs, etc.)

How active are you at your job? (e.g., desk job, standing, moving around frequently)

How many days per week do you currently work out or do intentional movement?

What types of exercise do you usually do (if any)?

Do you currently track your food?

Yes

Have you ever tracked macros before?

Yes

What does a typical day of eating look like for you? (Breakfast, lunch, dinner, snacks, beverages)

How much water do you typically drink per day?

Do you consume caffeine? If yes, how much per day?

Do you consume alcohol? If yes, how often per week?

Do you have any food allergies or intolerances?

Do you follow a specific dietary lifestyle? (e.g., vegetarian, dairy-free, gluten-free, etc.)

Do you have any current or past health conditions that affect your diet or digestion?

Are you taking any medications or supplements that impact your appetite, energy, or digestion?

Any history of disordered eating or food relationship challenges you'd like me to be aware of?

What are your main nutrition-related goals? (e.g., fat loss, muscle gain, energy, better habits, hormone balance, etc.)

How would you describe your current relationship with food?

What is your biggest challenge when it comes to nutrition?

What’s worked well for you in the past (if anything)?

Are there any foods you love and would like included in your plan?

Are there any foods you dislike or want to avoid?