NUTRITION INTAKE FORM
First Name
*
Last Name
*
Phone
*
Email
*
Gender
*
Male
Female
Age
*
Height
*
Weight
*
Health Goal
*
Lose Weight
Maintain
Gain Weight
Activity Level
*
Sedentary
Lightly Active
Moderately Active
Very Active
Extremely Active
Body Fat Men
*
Low: Under 13%
Medium: 14-22%
High: 23-30%
Too High: Over 31%
Unknown
Body Fat Women
*
Low: Under 22%
Medium: 23-31%
High: 32-39%
Too High: Over 40%
Unknown
Would you like to set a weight goal?
*
Yes
No
What is your weight goal?
*
Are you currently taking supplements?
*
Yes
No
Do you struggle with...
*
Losing weight
Gaining weight
Poor Sleep
Low Energy
Recovering from workouts
Constipation or loose bowels
None of the above
Are you willing to take supplements?
*
Yes
No
Some
Food Preferences
*
Anything
Paleo
Keto
Vegetarian
Vegan
Mediterranean
Other
List 5 foods that you DO NOT like & want to exclude from your meal plan.
*
Food Allergies
*
Gluten
Peanuts
Eggs
Dairy
Fish
Shell Fish
Soy
Tree Nuts
Night Shades
None Known
Other
Comments or Questions
Thank you for completing the Intake form!
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