Nutrition Consultation Form |

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Nutrition Consultation Form

This form will take around 15-20 minutes to complete. Please make sure you can commit to this and complete the form as honestly as possible. The more information I have, the better I will be able to help you!

Name *

First

Last

Phone Number *

Include Area Code

Email *

Gender

Female
Male
Other

Age

Selected Value: 0

Height (in cm) *

Weight (in kg) *

Body type

I am tall and I struggle to put on muscle or fat.
I am small with wide hips, narrow shoulders and struggle to lose weight.
I have naturally broad shoulders and I can quite easily put on muscle mass.
Other

Select the body type most relevant to you

How would you describe your occupational activity level?

My job is sedentary (office work, work from home, etc)
My job is active (waiter, plumber, tour guide, etc)
My job is extremely active (builder, fitness instructor, miner, etc)
I do not work or I am retired

How would you describe your non-occupational activity level?

Inactive- up to 100 minutes of light physical activity per week such as walking or deep house cleaning.
Moderate-Around 150 minutes of light to medium intensity exercise per week such as walking the dog, jogging or light strength training.
Active- Up to 200 minutes of light to intense exercise per week such as walking the dog, running, HIT training or strength training.
Very active- Over 200 minutes of moderate to high intensity exercise per week such as athletic or competition training

If applicable, please slide the slider to your desired long term weight loss goal (12 months)

Selected Value: 0

in pounds (lb)

If applicable, please slide the slider to your desired long term muscle gain goal (12 months)

Selected Value: 0

in pounds (lb)

Which of the below short term goals (up to 3 months) are most applicable to you?

To be in a calorie deficit (lose weight)
To be in a calorie surplus (gain weight)
To eat more fruits and vegetables
To eat more protein
To binge less on unhealthy snacks
To eat a vegetarian diet
To eat a vegan diet
To try new foods
To decrease my salt intake
To improve my diet for my sport
To become better at meal prepping
To include more meat in my diet
To make my diet more diverse

Please select 3 maximum

Do you have any food allergens? *

Do you have any food intolerances?

Do you have dietary requirements? E.g. vegetarian, vegan, etc *

Do you binge eat when you´re stressed, if so what do you eat? *

Do you drink alcohol? *

Yes
No

If you drink alcohol, how much do you drink?

The more honest you are, the better I can help you!

Have you ever tried meditation? *

Yes
No

What do you know about the relationship between the gut and brain, if anything? *

Have you experienced disorded eating, if so when, how long did it last, and what type of disordered eating? *

Have you ever followed a low calorie diet? 1200 calories or less per day for longer than 1 month? *

Have you ever followed a meal plan? *

Yes
No

Have you ever used my fitness pal? *

Yes
No

Has your weight changed over the years? If so, what changes have you noticed and when? Were there any significant events that occured around these changes such as low calorie diets, stressful events? *

Does your gut react to certain situations? I.e. More bowel movements in stressfull situations *

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