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Nutrition
Consultation Form
(This form only needs to be filled out once unless updating information) 

CONTACT INFO

How did you hear about our services? Required
Are you under the care of a medical doctor? Required
Recent surgical procedure? Required
Tobacco/Nicotine use? Required
Alcohol use? Required
Soda/Soft drinks? Required
Sweetended drinks/ice cream/smoothie bowls? Required
Hours of Sleep? Required
Physical demands of job? Required
What is general stress level? Required
Were you overweight as a child/teen? Required
During the day do you... Required
What type of groceries do you normally eat? Required
How often do you eat fast food/restaurant food? Required
How often do you cook your own food from whole/fresh ingredients Required
Dietary Restrictions (please check ALL that apply): Required
Digestive Discorders (please check ALL that apply): Required
How many times a day do you eat? Required
What do you crave most? Required
Do you skip meals? Required
Do you eat late at night? Required
Do you know how many calories you eat in a day? Required
Do you feel your energy level drop during the day? Required
Besides hunger, what other reasons cause you to eat? Required
Do you eat past the point of fullness? Required
Do you feel guilty about leaving food on your plate? Required
Do you eat foods high in fat/sugar? Required
Do you eat when you are NOT hungry? Required
How often do you exercise? Required
What type of exercise? Required
Have you been exercising consistently for the past 3 month? Required
Conditions (please check ALL that apply): Required
If Pregnant, are you breastfeeding?
Do you have an appointment date yet? Required
Which Coach have you selected? Required

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