Nutrition Client Intake Form – Meathead Athletics

Basic Info

Tell us a little about yourself.

Name

How is your name pronounced?

Today's Date

Month

Day

Year

E-mail

Birthdate

Month

Day

Year

Gender

Heightin/cm - please label

Weightkg/lbs - please label

Health History

Please answer the following questions.

Has a doctor diagnosed you with a heart condition?YesNo

Do you experience sharp pain or extreme tightness in your chest in cold temperatures?YesNo

Do you have or have you had diabetes, hypertension, or high blood pressure?YesNo

Does anyone in your family have diabetes, hypertension, or high blood pressure?YesNo

Have you experienced rapid heartbeat or palpitations?YesNo

Have you ever or do you take medications or been on a special diet to lower cholesterol?YesNo

Are you overweight?YesNo

Are you under excessive stress?YesNo

Do you drink?YesNo

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?YesNo

Do you have any food allergies or intolerances?YesNo

Have you been diagnosed with an eating disorder?YesNo

Lifestyle Info

Just a few more things we need to know.

Do you cook?YesNo

During the week, how often is dinner made at home?

How many caffeinated drinks do you have a day?

If there's anything we missed, please list here.