ELEVATE NUTRITION INTAKEInterested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! DISCLAIMER Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision. I agree, recognize and accept the disclaimer. * Yes No GENERAL Name * First Name Last Name Email * Phone * Country (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * Country (###) ### #### Height * Specify in inches or cm Weight * Specify in kg or lbs Goal Weight * Specify in kg or lbs GOALS In general, what are your goals? * Check all that apply Lose weight Maintain weight Gain weight Add muscle Look better Feel better Have more energy Improve physical fitness Get control of eating habits Get stronger Improve athletic performance Manage health issues Other Please list all of your concerns about your health, eating habits, fitness and/body. * Out of all the above concerns, which ones feel the most important / urgent? Why? (Pick 1-3 concerns) * Have you tried anything in the past to change your habits, your health, your eating, and / or your body? If so, what? * Which of those things worked well for you? (Even if you might not be doing it right now) * Which of those things didn't work well for you? * How, specifically, would you like your habits, your health, your eating, and / or your body to be different? * Have you already made changes to your habits, your health, your eating, and / or your body recently? If so, what? * If you were to consider making further changes to your habits, your health, your eating, and / or your body, what might those be? * Until now, what has blocked you or held you back from changing these things? * FOOD AND HEALTH Right now, are you following any particular diet or style of eating?(e.g., vegetarian / vegan, Paleo, kosher / halal, low-carb) * Yes No If yes, what? And for how long have you followed this way of eating? What are some of the foods or meals you like MOST? * What are some of the foods or meals you DON’T like? * How CONSISTENT would you say you are with your eating habits? * All over the place Consistent for a day or two then it all derails Consistent during the week then derailed on the weekends Perfectly consistent all the time If you’re less consistent than you’d like to be, what seems to get in the way or knock you off track? * Do you have any known / diagnosed food allergies or intolerances? If yes, what are those? * Do you have any suspected or possible food allergies or intolerances? If yes, what are those? * How often do you have a bowel movement? * More than 3 times daily 2-3 times daily 1-2 times daily Once every 2-3 days A few times a week Weekly or less Do you have any digestive system complaints right now? If yes, what are those? * Are you biologically meant to have a menstrual cycle? * Yes No If yes to the above, please tell us more about your cycle I no longer have a period because of menopause I no longer have a period because of contraceptives I no longer have a period and I don't know why I have a cycle but it is irregular month to month I have a cycle and it is mostly regular I have a cycle and it is very regular On average, how many hours per night do you sleep? * 4 or less 5-6 6-7 8 9+ Do you wake up in the middle of the night? If yes, how many times and why? * Have you been diagnosed (currently or in the past) with any significant medical conditions? * Yes No Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries? * Are you taking any medications, prescription or over-the-counter? * Yes No Please list any supplements you are taking, if you are comfortable sharing this information) Includes magnesium, creatine, etc. HUNGER CUES AND APPETITE How would you describe your normal appetite / hunger? * Never hungry Sometimes hungry Just right / do not notice Usually hungry Always starving Do you feel like you have trouble controlling your appetite / hunger? * Yes, I feel like I always want food / eating runs my life Sometimes / it depends No Do you normally struggle with food cravings? * Yes, often Sometimes / it depends No, rarely If yes or sometimes, what do you normally crave? What do you do when you have cravings? Have you ever noticed any connection between your emotions and your eating habits? If yes, what happens? * (e.g., When I’m feeling sad I use food to comfort myself; when I’m happy I notice I have fewer cravings) Have you ever noticed any connection between stress and your eating habits? If yes, what happens? * (e.g., When I’m stressed I eat more / less) How often do you think about food and eating? * Never Rarely Sometimes Often Almost always If you think about food and eating more than sometimes, what in particular do you think about? How often do you eat to the point of being full or stuffed? * Never Rarely Sometimes Often Almost always If you feel you’ve eaten too much, what do you do afterwards? * Check all that apply. Try to eat less at subsequent meals Skip the following meal Try exercise to burn it off Feel bad Try to get back in control of things Purge by vomiting or using laxatives Forget about it and go back to normal eating Keep eating ... what the heck, already blown it Other How often do you skip meals or purposely go a long time without eating? * Never Rarely Sometimes Often Almost always DAILY HABITS AND ENVIRONMENT Who all lives with you? * Check all that apply Spouse or partner(s) Child(ren) Roommate(s) Pet(s) I live by myself Parent(s) / Guardian(s) Other If you have children, how many and what are their ages? How often do you normally make meals at home? * 0 meals 1-2 meals / day 3-4 meals / day All meals are prepared at home How often do you eat meals in a restaurant or order take-out/delivery? * 0 meals 1-2 meals / week 3-4 meals / week 5 or more meals /week How often do you shop for food? * Check all that apply More than daily Daily A couple times a week Once a week Less than once a week I order groceries to be delivered at home I never shop for food Other Who does most of the grocery shopping in your household? * Check all that apply Spouse or partner(s) Child(ren) Roommate(s) Me Parent(s) / Guardian(s) Other How would you rank your food preparation and cooking skills right now? * Terrible / nonexistent Not too terrible but I need help I'm not too bad, not too good I'm decent at it Expert chef Who does most of the cooking in your household? * Check all that apply Spouse or partner(s) Child(ren) Roommate(s) Me Parent(s) / Guardian(s) Other Who decides on most of the menu/meal types in your household? * Check all that apply Spouse or partner(s) Child(ren) Roommate(s) Me Parent(s) / Guardian(s) Other Do you like cooking? * Yes Sometimes, if I have the time/energy No If no, what do you NOT like? If yes or sometimes, what do you enjoy about it? * In an average week, how many hours do you work? * 10 or less 10 - 20 20 - 30 30 - 40 40 - 60 60 + In an average week, how many hours do you spend at school or doing school work? * 10 or less 10 - 20 20 - 30 30 - 40 40 - 60 60 + In an average week, how many hours do you spend travelling or commuting? * 1-2 / day 5 - 10 10 - 20 20 - 30 30+ In an average week, how many hours do you spend taking care of others? * (children, person with a disability, elderly parent, etc.) None 10 or less 10 - 20 20 - 30 30 - 40 40 - 60 60 + Do you have a hobby and how many hours do you spend on it in an average week? * How do you feel about your schedule, time use, and overall busy-ness? * My life is panicked and insane My life is too busy most of the time My life is too busy sometimes / depends on the time of year My life isn't too busy, I get down time My life is calm and relaxed What is your typical stress level on an average day? * Very stressed Usually stressed Sometimes stressed Rarely stressed Never stressed How do you cope with stress? * ACTIVITY How active are you? * Not including purposeful exercise Very light : sitting most of the day / desk job Light : a mix of sitting, standing, light activity Moderate : continuous, spend most of my time standing Heavy : strenuous, spend most of my day standing and do heavy lifting / physical work Are you regularly active in sports and/or exercise? * Yes Sometimes, depends on the season No What types of sports or exercise do you typically do? * What best describes your weekly workouts? * Very light : almost no purposeful exercise Light : 1-3 hours of gentle / moderate exercise Moderate : 3-4 hours of moderate exercise Intense : 4-6 hours of moderate to strenuous exercise Very intense : 7+ hours of strenuous exercise How many hours per week are you active in sports/exercise? * Less than 5 5-7 7-10 10-15 15+ What type of purposeful exercise do you typically do? Do you have any specific exercise / sports goals? Competitions, tournaments, etc. SUMMARY Thinking about all that you have answered, what do you think you might like to start working on or addressing first? * Right now, how much do the people and things around you support health, fitness, and / or behavior change? * Not at all supportive Rarely supportive I don't know / I live by myself Sometimes supportive Always supportive Please add any additional comments or information you feel we should know. Thank you!A coach will review your answers and reach out to you in 1-5 days with your next steps.If you have not already, please click on the link below and create a profile on MyFitnessPal.
