NAME
EMAIL
CURRENT WEIGHT
GOAL WEIGHT
AGE
18-24
25-29
30-34
35-39
40-44
45+
Reason(s) for seeking out a nutritionist + healthy living coach
Have you worked with a healthy living professional (nutritionist, trainer, coach) in any capacity?
If you answered YES to the above: What type + when? What did you achieve? What didn’t you like about previous experiences?
Have you dieted in the past? What diets have you tried + what were the results?
Have you had any dramatic weight gains or losses in the last year? If so, explain below:
Write your food and drink intake below for the last 3 days
Grocery shopping habits: How often do you go to the grocery store? Do you go with a list? Where do you shop?
List 5 of your top restaurants or food delivery places you order from + write out the menu items you order
YOUR DAY: how many meals and snacks do you eat in a day?
Now, think through these answers and try to place what you ate at mealtime if you felt “sick” (nauseous, bloated, gassy…)
If you answered up and down throughout the day above, explain the times of day you are at highest energy and lowest.
Describe your weekly workout routine including your workout type, frequency, and duration.
What do you think you would benefit from most when it comes to guidance regarding fitness?
Write down any wellness practices you do regularly. (I.E. light therapy, infrared sauna, meditation or digital detox, detox/salt baths, journaling, massage, et al.)
What are your biggest stressors in your daily life? These can be listed categorically (financial, love life, parenting, work, et al.) or specific/situationally.
On a scale from 1-10, how stressed are you from day-to-day?
When (+ where) do you feel most at peace and balanced?
Who acts as your biggest support system on a daily basis? Will they be on board for healthy living changes?
What is your ideal budget when it comes to health + wellness services per month?
$0-25
$26-99
$100-149
$150-199
$199+
Submit
If you are human, leave this field blank.
