Name
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First Name
Last Name
Email Address
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Height
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Weight
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Recent body composition (if known; % body fat)
Date of Birth
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MM
DD
YYYY
Occupation
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If applicable, what is your work schedule and hours worked per week?
Marital status
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If you have children, how many and what ages?
Are you currently following a particular dietary pattern such as vegan/vegetarian, Paleo, gluten-free, etc.? Please share details.
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Please list any foods you dislike or will not eat (along with reasons), and specify whether you have known food allergies or sensitivities:
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Do you like to cook?
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How often do you dine out on a weekly basis? Please provide any details you would like to share.
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What are your main nutrition-related challenges and concerns related to your everyday nutrition?
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Any other lifestyle details to share that pertain to or affect your nutrition patterns?
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Race, Competition, or Event Calendar:
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Please provide an example of a “typical” nutrition day for you.
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For example:
Breakfast 7am: oatmeal with milk, banana; 16 oz coffee with half and half
Snack 10am: Clif bar
11am: usually do 45-75 min run or swim
Lunch 12:30pm: turkey and swiss on rye, apple
3pm: crackers with hummus, cheese stick. Sometimes small cappuccino
5pm: strength workout 3x/week
7:30pm: chicken breast, broccoli, wild rice with butter; usually have gelato afterwards
Do you currently have any diagnosed medical conditions such as diabetes, hypothyroid (or other thyroid conditions), PCOS, cancer, IBD/IBS or other bowel condition? If so, please explain:
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Do you have disordered eating or a clinically diagnosed eating disorder, or have you dealt with this in the past? Please explain:
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Please list in detail all medications, supplements (vitamins, minerals) and any other herbal or nutritional products you take. Include brand name, dosage, and time of day you take.
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Any other information you would like to share related to nutrition?
For females, are you taking any hormone replacement therapy, oral contraceptive or do you have an intrauterine device? If yes, provide details (such as brand name, how long you have been taking, etc.).
For females, if you have menstrual periods, what is the average duration of your monthly cycles and periods? How heavy is blood loss?
