Nutrition Intake Form

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information.

Are you currently taking any medications or supplements? If yes, please list them.

Do you have any known food allergies or intolerances? If yes, please specify.

Do you currently follow any specific dietary pattern (vegan, vegetarian, gluten free, etc.)?

What is your everyday life like (work, school, family, other commitments)?

What are some good days and times for our bi-weekly calls that work best with your schedule? (Can be changed anytime.)

What does a typical day of meals and snacks look like for you?

How consistent is your daily routine (meals, sleep, schedule)?

On average, how many hours of sleep do you get per night?

How would you describe your current stress levels?

Low

Moderate

High

What helps you manage stress when it comes up?

Do you currently exercise or engage in physical activity? If so, what kind and how often?

How would you describe your overall energy levels throughout the day?

Do you track your food intake or any health data (macros, calories, weight, sleep, etc.)?

What foods or eating patterns make you feel your best? What tends to make you feel worse?

Do you experience digestive issues, energy crashes, or strong cravings regularly? If yes, please describe.

How would you describe your current relationship with food?

Do you ever feel guilt, stress, or anxiety around eating?

Have you ever worked with a nutritionist, dietitian, or coach before? If so, what was that experience like?

Do you have any history of disordered eating or restrictive patterns you’d like me to be aware of?

What are your main goals for nutrition or health coaching? Examples: improve energy, better balance, consistent meals, gut health, body composition, stress management, etc.

What feels most challenging for you right now when it comes to nutrition or lifestyle habits?

What are your short-term goals (next 3–6 months)?

What are your long-term goals (6+ months)?

What would “success” in this coaching relationship look like for you?

How would you like me to support you most - education, structure, accountability, mindset, or all of the above?

Is there anything else you’d like me to know before we begin?

Initials

I declare that the info I’ve provided is accurate and complete.

I have read and agreed to the Terms and Conditions, and Privacy Policy.