Please fill out your intake form and select your nutrition coach at the bottom to ensure they receive it!

After submitting, you’ll receive an email with a link to book your 45 Minute Onboarding Call!

Nutrition Intake Form

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Name *

First

Last

Email *

Phone *

How Do You Prefer To Be Contacted *

• Email
• Phone
• Text / Whatsapp

Gender *

• Male
• Female

Date Of Birth *

Age *

Height (ft and inches) *

Weight *

Goal Weight

What Are Your Main Goals?

• Lose Weight / Fat
• Build Lean Muscle Mass
• Maintain Weight
• Look / Feel Better
• Increase Energy & Vitality
• Get Eating Habits Under Control
• Physique / Fitness Competition
• Powerlifting Competition
• Improve Athletic Performance

Daily Activity, Sports, Exercise, Walks..etc

What Are Your Fitness and Health Goals?

What Have You Tried in The Past To Achieve These Goals? Other Fitness Programs, Personal Training, Weight Watchers, Supplements..etc

What Barriers Do You Feel Are Preventing You From Achieving Your Goals?

What Best Describes Your Current Nutrition Approach?

• Vegan
• Vegetarian
• Keto
• Pescatarian
• Paleo
• Mediterranean
• High Protein
• Low Carb
• Gluten Free
• Celiac
• Lactose Free
• No Restrictions or Direction

How Would You Rate Your Current Eating / Nutrition Habits?

Selected Value: 0

Do You Exercise Regularly?

• Yes
• No

If Yes, What Type of Exercise?

How Many Steps Per Day Do You Get?

• 10,000+
• 5000 - 10,000
• Less Than 5000

Who Lives With You?

• Spouse
• Roommate
• Children
• Pets
• Parents / Family

Who Does Most Of the Cooking?

• Me!
• Spouse
• Other
• Nobody, we order in

Who Does The Grocery Shopping?

• Me!
• Spouse
• Other

How Much do the People In Your Life Support Your Nutrition and Fitness Goals?

Selected Value: 0

Are You Taking Any Medication or Have Any Medical Concerns? (Ozempic, Thyroid, Celiac..etc)

How Do You Feel About Your Schedule, Available Time To Meal Prep, Workout, Grocery Shop, and Overall Daily Routine?

• Very Flexible, Lots of Time
• Busy But I Can Make It Happen
• Very Busy, Will Probably Need a Meal Delivery Service

Rate Your Daily Stress Levels

• Really Stressed
• Somewhat Stressed
• No Stress

How Do You Manage Your Stress?

Average Hours of Sleep Per Night

Selected Value: 0

How Ready / Willing Are You To Change Your Life?

Selected Value: 0

Any Additional Details You Feel We Should Know?

Which Coach Are You Working With? *Kristin LegardJennifer MulgrewNot Sure

Submit

After submitting, please check your email for your booking link!