All about YOU:

Name:

1.   Have you ever received a nutritional or Fitness consultation?

     Yes No
If Yes please explain

2. Explain why you would like to receive Nutrition counseling at this time.
(select all those that apply by holding the control key while clicking)

   Coach/Trainer or Doctor Advised To Enhace Athletic Performance Want to Know More About Nutritional Supplements I Need to Gain Weight I Need to Lose Weight I would Like More Information on Foods to Eat Before,During, and After Exercise I Think I May Have an Eating Disorder What Foods are "Super Foods" increasing Energy and Help Prevent Disease

3. What are your long term goals?  List three.

    4.  What are your short term goals? List three.

         

    5.  Do you workout?  When?  How often?  How long?

    

Nutrition History

1.    What is your:

a. Current Weight

b. Height

c. Body composition

d. Date of birth

 

Your food intake for the day

Please type down a typical day of food intake.  Include water, juices, snacks, fruit, veggies, dairy, and meat and alcohol.

 

Are you currently taking any medications?  Please list. 
 

Please list injuries or conditions that may slow your progress

Realistically please list what you would like to accomplish

in the next 8 weeks.

Enter any other comments in the space provided below:

 

 

E-mail:

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