Full Name

Phone *

Email *

Gender:

Height (' & "):

Weight (lbs)

How Active Are You? (1-4):

Address

Street Address

City

State

Country

Postal code

HEALTH & WELLNESS GOALS

What are your primary wellness goals?

Do you have any specific concerns you’d like us to address?

HEALTH HISTORY

Do you have any medical conditions or injuries we should be aware of?

If yes, please specify:

Are you currently on any medications or treatments that may affect your wellness plan?

Yes, please specify:

Do you have any Food Sensitivities or Allergies?

Food Log

What do you typically eat for Breakfast?

What do you typically eat for Lunch?

What do you typically eat for Dinner?

What do you typically eat for Snacks?

How often do you eat out?

How much water do you drink per day?

Foods we will use to make your meal plan!

Please list 4-5 Carbohydrates that you like (rice, pasta, bread, potatoes, etc)

Please list 4-5 Proteins that you like (chicken, fish, eggs, beef, lentils, etc)

Please list 4-5 Fats that you like (oils, butters, nuts, seeds, etc)

Please list 4-5 Vegetables that you like (broccoli, spinach, carrots, peas, etc)

Please list 4-5 Fruits that you like (apples, bananas, oranges, etc)

Please list 4-5 Snacks that you like (crackers, granola bars, fruits, veggies, etc)

Taste Preferences

How Spicy do you like your food?

What styles of cuisine do you like? (Italian, Mexican, Chinese, etc)

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