1. Have you ever received a nutritional or Fitness consultation?
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)
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?
1. What is your:
a. Current Weight
c. Body composition
d. Date of birth
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: