Nutritional Intake & Screening Form Nutritional Intake & Screening Form Name * Name First Name First Name Last Name Last Name Phone * Email * Body & Nutrition Information Current Body Weight lbs Enter your desired weight in pounds (lbs) Desired Body Weight lbs Enter your desired weight in pounds (lbs) Height Recommended Daily Calories calories Nutrition Application Used Fitness & Training Goals What are your fitness/training goals? Nutrition Goals What are your nutrition goals? Performance Goals What are your performance goals? Previous Programs & Supplements What have you previously tried to achieve your nutrition and fitness goals? Include diets, exercise programs, supplements, books, coaching, etc. Do you currently use any nutritional or performance-enhancing supplements? Yes No Please list your nutritional/performance supplements. Please include the supplement name/brand, how much you take, when you take it, and its intended purpose. Do you take any vitamin or mineral supplements? Yes No Please list your nutritional/performance supplements. Dietary Preferences Are there any foods that you avoid? Yes No Please list the foods you avoid. Do you follow a vegetarian, vegan, or pescatarian diet? Yes No Which eating pattern best describes you? VegetarianVeganPescatarianOther Which eating pattern best describes you? Which foods do you NOT eat? Caffeine & Tobacco On average, how many caffeinated beverages do you consume per day? 123456789101112+ What types of caffeinated beverages do you consume? Coffee Tea Energy Drinks Soda Pre-Workout Other Do you currently smoke tobacco products? Yes No Approximately how many cigarettes do you smoke per day? 123456789101112+ Sleep & Health Screening On average, how many hours do you sleep on weeknights? On average, how many hours do you sleep on weekends? Are there any health conditions that limit your ability to be physically active or make dietary changes? Yes No Please explain any health conditions or limitations we should be aware of. Health & Nutrition Notice: Information submitted through this form is used to better understand your nutrition, fitness, and wellness goals. Nutrition and fitness coaching is not a substitute for medical diagnosis, treatment, or individualized medical advice. Please consult a qualified healthcare professional before making significant changes to your diet, exercise routine, supplements, or other health practices, particularly if you have an existing medical condition. Acknowledgment * I confirm that the information I have provided is accurate to the best of my knowledge, and I understand the health and nutrition notice above. Submit If you are human, leave this field blank.