Do you shop more for convenience or budget?
Do you like to cook?
On a scale of 1-10, how would you rate your current nutrition?
1 what is a vegetable?
10 super healthy and on point
List 3 beverages that you drink dally
What do you struggle with most when it comes to your nutrition?
What is your favorite comfort food?
Typical time first meal of the day is eaten:
Typical time of the day kitchen closes at night:
What do you typically snack on?
Please list any current medications.
What have you done in the past to work on this area? (include both alternative and traditional modalities)
What has proven effective?
What would you like your health to be like 6 weeks from now? How about 6 months? How would you feel if you got this result?
How often do you drink alcohol?
I do not drink
1-2 drinks per week
2-4 drinks per week
1-2 drinks per day
How much water do you drink each day?
Wait, I'm supposed to drink water?
How often do you read for pleasure or personal growth?
Every few days
Every few weeks
Every few months
My current job is
sedentary (desk job)
moderately active (retail/restaurant/on your feet for some/most of the day)
very active (manual labor/construction/sports)
Share a food journal, outlining a "day in the life." (Please be specific! List standard breakfast, lunch, dinner, snacks, as well as the times you eat.)
Are there any special dietary considerations that need to be made when designing your meal plan?
What are 5 things you LOVE about your life?
Please include anything else you would like to share!
THANK YOU! I have received your intake form.
You are on your way!