Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Gender
*
Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
How do you prefer to be contacted?
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Email
Video Call
Text
Current Weight
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Height(cm)
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In general, what are your goals? (Check all that apply)
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Lose weight/fat
Gain Weight
Maintain Weight
Build Muscle
Look Better
Feel Better
Improve Physical Fitness
Become Stronger
Increase Energy
Improve Eating Habits
Prepare for a compeition
Please list all concerns you have about your eating habits, health, fitness, and/or body.
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Of all the concerns above, which feel the most important to you?
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What are some things you expect from your nutrition coach?
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Have you tried anything in the past to improve your eating habits, health, fitness and/or body?(if so, what?)
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Which of those things worked well for you?
Which of those things did not work well for you?
How, specifically, would you like your eating habits, health, fitness, and/or body to be different?
Until now, what has blocked you from making changes?
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Right now, how would you rank your eating/nutrition habits?
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10-Awesome!
9
8
7
6
5-Average
4
3
2
1-Horrible!
How many times do you eat per day?
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Describe your typical Breakfast.
What time of the day do you eat Breakfast?
Describe your typical Lunch.
What time of the day do you eat Lunch?
Describe your typical Dinner.
What time of the day do you eat Dinner?
Describe your typical Snacks.
What times of the day do you eat Snacks?
How many meals per week do you eat out?
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None
1-2
3-4
4+
If you eat out, what is the most common meal you will eat out for?
Approximately how many hours per week do you spend doing exercise/sports?
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Fewer than 5 hours
5-9
10-14
15-20
20+ hours
What type of sports/exercise do you typically do?
Approximately how many hours a week do you perform other forms of activity?(housework, walking dog, gardening)
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Fewer than 5 hours
5-9
10-14
15-19
20+ hours
What types of activities do you do?
Who lives with you?
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Solo
Spouse or Partner
Children
Roommate
Other family(parent, grandparent)
Do you have children? If so, how many and what are their ages?
Who does most of the grocery shopping in the household?
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Me
Spouse or Partner
Child
Roommate
Other family
Who does most of the cooking in the household?
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Me
Spouse or Partner
Roommate
Child
Other family
Do you have any challenges with preparing food?
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Which food prep style best describes you?
I like to prep food in advance and eat the same meals for a few days
I want to spend more time cooking and have different meals each day
Right now, how much do the people and things around you support health, fitness, and behaviour change?
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10-Completely supportive
9
8
7
6
5-Somewhat supportive
4
3
2
1-Not at all
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
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Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
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Yes
No
Right now, are you taking any medications, either over-the-counter or prescription?
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Yes
No
On a scale of 1-10, how would you rank your health right now?
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10-Amazing
9
8
7
6
5-Average
4
3
2
1-Horrible
Why?
Do you have any digestive issues?
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Yes
No
If yes, what kind?
Do you have a bowel movement every day?
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Yes
No
If no, how often?
In a typical week, where do you spend your time?(check all that apply)
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paid employment
taking care of others(children, family)
doing school work
unpaid work(housework, errands)
commuting/travel
volunteering
Approximately how many hours total are spent on these in a week?
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
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10-My life is calm and relaxed
9
8
7
6
5-I somehow manage all the stress
4
3
2
1-My schedule is packed and chaotic
Given all the demands of your life, what is your typical stress level on an average day?
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10-Extreme Stress
9
8
7
6
5-Average
4
3
2
1-No Stress
On average, how many hours per night do you sleep?
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4 or fewer hours
5-6
7-8
9+ hours
How do you normally cope with your stress?
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Is there anything that scares you or intimidates you about following a nutrition plan?
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How READY are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
How WILLING are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
How ABLE are you to change your behaviors and habits?
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10-Completely
9
8
7
6
5-Maybe
4
3
2
1-Not at all
Disclaimer
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Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking
nutrition and / or fitness consultation.
Any information provided is not to be followed without prior approval of your doctor.
If you choose to use this information without
such approval, you agree to accept full responsibility for your decision.
First Name
Last Name