Name * First Name Last Name Email Address * Phone (###) ### #### Age Height Weight Are you currently pregnant or breastfeeding? Do you have any health related problems that I need to be aware of? Have you been diagnosed with either diabetes or thyroid disease? What are your fitness goals? Weight loss (how much,) muscle gain, maintenance? What is your current diet like? Please be as detailed as possible and include if you already follow some type of specific diet regimen or count calories. Aside from any training I am providing you with, what does your physical activity consist of on a daily basis? What are the biggest struggles you face when committing to a healthy lifestyle? What are the foods that most often throw your diet off, you binge on, or you have trouble saying "no" to? Are there certain activities that lead to a negative change it your diet? Ex: eating out, going out with friend, Netflix bingeing? How much/how often do you consume alcohol? What are the main kinds? Do you suffer from digestive issues? Have you been diagnosed with a vitamin deficiency? What current vitamins or supplements do you take if any? How much caffeine do you consume daily? How much structure is ideal to you in a diet program? Do you prefer to be able to choose your own foods and change them daily or to have a set meal plan that doesn't have much variation? Do you plan to prepare at least some of your meals ahead of time? As a disclaimer, I am not a nutritionist or registered dietician. I am a certified personal trainer with weight loss and fitness success based largely on IIFYM practices. Please consult a physician if you are looking to be referred to a nutritionist instead! Please type your name as an acknowledgement of understanding: Thank you!
