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NUTRITION CONSULTATION QUESTIONNAIRE
Please fill out the following information. You will be guided to the purchase portal upon completion.
First name
Last name
Email
Code
Phone
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Coach I will be working with:
*
Eric Northington
Derek Jansen
Kim Bass
Jazmin Gonzalez
Amanda Giles
Bernice Tomaso
Choice 1
Age
Weight
Height
Waist measurement, in inches, at smallest portion of waist
What is your goal?
*
Fat Loss
Muscle Building
Body Re-composition
Increase Metabolism/Reverse Diet
Describe your past coaching experience
Describe in detail a typical weekday from the time you wake up to the time you go to bed
If you are currently employed, how many hours per week do you work?
If you use an activity tracker, what is the average number of steps that you log daily?
Are you responsible for any young children?
Describe exactly what you ate and drank over the last 3 days (separate each day)
How many ounces of water do you drink per day?
How many alcoholic beverages do you typically consume per week?
*
1 or less per week
2-4 per week
More than 4 per week
How many meals per week do you eat outside of your home?
*
1 or less per week
2-4 per week
More than 4 per week
Describe your training regime
What is your current supplement regime?
How has the current fitness and nutrition routine effected your weight and physique?
Do you have any major events, vacations, etc, coming up in the next 3 months?
List your weight 3 months, 6 months, 12 months, and 18 months ago.
Have you been diagnosed as diabetic, with kidney disease, or have a history of thyroid problems?
Do you have any known hormone imbalances?
Please list any known medical or food allergies, or dietary restrictions
Special considerations (current or past injuries, surgeries, medical conditions, or medications, all past or present)
Do you know what a macronutrient is? If so, please write the caloric amount per gram each macronutrient yields.
Please tell me as accurately as possible how many calories per day you have been consuming?
If they are not listed above, can you tell me foods you prefer and enjoy consuming?
How many years of weight training experience do you have?
Front of physique
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Back of physique
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Side of physique
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May I share your images on my personal social media channels?
*
Yes
No
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Your Facebook URL
Your Instagram URL
Who can we thank for the referral, or how did you hear about us?
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