1:1 Nutrition Coaching - Intake Questionnaire Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Emergency Contact Name & Relationship * Emergency Contact Phone Number * What does your daily activity look like between work, exercise, & other movement? * Approximately how many hours are you active in sports / exercise per week? * 0-5 5-10 10-15 15+ What types of exercise / movement / sports do you typically do? * Does anyone live with you? * *Women Only* Do you have a regular menstrual cycle? If not, please explain. * Who handles grocery shopping / cooking in your household? (Select all that apply) * Myself Parents Roomates Spouse Other Have you ever been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries? If yes, list all that apply. * Right now, are you taking any medications, either over-the-counter or prescription? If yes, list all that apply. * Right now, are you taking any supplements? If yes, list all that apply. * Do you have any known allergies? * How do you feel about your schedule, time use, and overall busy-ness? * 1 My life is relaxed & calm 2 3 4 5 My life is crazy busy & insane How do you normally cope with your stress? * On average, how many hours per night do you sleep? * 4 or less 5-6 6-7 7-8 8+ Which phrases sound most accurate when describing your eating habits? * I am distracted when I eat (ie. scrolling on my phone, watching TV) I eat my meals quickly I feel obligated to finish the food on my plate even when I'm no longer hungry Eating is not enjoyable for me and feels like a chore Most of the time I eat my meals seated at a dining table (or other surface specifically intended for eating) I eat according to a routine rather than based on when I am hungry I find myself snacking throughout the day I feel the need to finish my meals with something sweet I tend to restrict my food throughout the day and end up bingeing at night None of these apply to me Is there anything from the above checklist you'd like to elaborate on? The more details you provide me, the better! * What diets have you tried in the past 2-3 years? What has worked / what hasn’t & why? * Do you have any experience with tracking food or macros through an app like My Fitness Pal? If yes, has tracking your food become a trigger for binge-eating in the past? * Please elaborate on your goals / expectations from this program. (how much weight you wish to lose or gain, healthier habits around food, ending the binge-restrict cycle, etc). * Anything else you'd like me to know? Thank you!