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Our Services
Cart
Client Login
Merch
About
Basic Info
Tell us a little about yourself.
Name
*
How is your name pronounced?
Today's Date
Month
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1
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Day
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Year
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2122
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E-mail
*
Birthdate
*
Month
*
Day
*
Year
*
Sex
*
--
XX
XY
Height
*
in/cm - please label
Weight
*
kg/lbs - please label
Health History
Please answer the following questions.
Has a doctor diagnosed you with a heart condition?
Yes
No
Do you experience sharp pain or extreme tightness in your chest in cold temperatures?
Yes
No
Do you have or have you had diabetes, hypertension, or high blood pressure?
Yes
No
Does anyone in your family have diabetes, hypertension, or high blood pressure?
Yes
No
Have you experienced rapid heartbeat or palpitations?
Yes
No
Have you ever or do you take medications or been on a special diet to lower cholesterol?
Yes
No
Are you overweight?
Yes
No
Are you under excessive stress?
Yes
No
Do you drink?
Yes
No
Do you have a physical condition, impairment, or disability (including a joint or muscle problem) that should be considered before you begin a nutrition program?
Yes
No
Do you have any food allergies or intolerances?
Yes
No
Have you been diagnosed with an eating disorder?
Yes
No
Lifestyle Info and Food Preferences
Just a few more things we need to know.
What is your goal?
Lose weight
Build Muscle
Athletic Performance
Body Recomposition
Improve Health
Do you have a goal weight?
Yes
No
If you answered yes, what is your goal weight for 12 months from now?
What's your activity level?
Very Light (sitting most of the day, desk job)
Light (mix of standing and sitting, teacher)
Moderate (constant gentle to moderate activity, food service)
Heavy (strenuous activity throughout the day, construction)
Do you work out?
No
Light (1-3 hours a week)
Moderate (3-4 hours a week)
Intense (4-6 hours a week)
Very Intense (7+ hours a week)
Do you cook?
Yes
No
During the week, how often is dinner made at home?
--
Rarely/never
1-3 times
3-5 times
6-7 times
How many times a day do you want to eat?
*
What do you like to eat?
Anything
Mediterranean
Paleo
Vegetarian
Vegan
How many caffeinated drinks do you have a day?
--
None
1-2
2-4
4 or more
If there's anything we missed, please list here.
Submit
