CLIENT INTAKE FORM fill me out :) Intake Form BASIC INFO: First & Last Name * First Name Last Name Email * Phone * (###) ### #### Age * Height * Weight * Gender * Male Female GOALS & CURRENT HEALTH STATUS: Do you have any health concerns or hormonal concerns that you would like your coach to know about? * Do you have a normal menstrual cycle? List any details below. * Are you currently taking any medications (including birth control)? * Primary Goals? * - Fat Loss - Muscle Building (may require a calorie surplus; do not select of your main concern is the scale going down) - Maintenance (your focus is on health, habit building, and maintaining / improving your current physique) - Recovery Diet (I recently finished a fat loss phase and want to work my calories back up to maintenance) Please share a little bit more about your current goals or any secondary goals that may have not been listed * NUTRITION: Are you currently tracking calories and/or macros? If so, please give us your current calorie and macro targets * Tell me a bit about your current eating habits. What is currently working and not working? * Do you currently meal prep or plan any of your meals for the week? Do you enjoy cooking, meal prepping/ planning? * How would you describe your hunger levels throughout the day? Are there moments when you feel extremely hungry or do you feel a little disconnected from your hunger? * How many alcoholic beverages do you consume on average per week? * Check all that apply: * I have weighed out my food portions before I am currently weighing out my food portions more than 70% of the time I want to weigh out my food portions I have tracked my food in an app such as MyFitnessPal, Chronometer, MacrosFirst, etc. I want to track my food I would prefer not to weigh/measure my food MINDFUL EATING: How would you describe your eating speed? * Do you tend to eat on the go or while multitasking? * Yes No How likely are you to finish a large plate of food even if you’re full? * 1 2 3 4 5 6 7 8 9 10 How likely are you to eat a meal while thinking about what you have to do later? * 1 2 3 4 5 6 7 8 9 10 How likely are you to eat past fullness if you’re eating a particularly tasty food? * 1 2 3 4 5 6 7 8 9 10 How likely are you to eat to feel better/less stressed/in response to another emotion? * 1 2 3 4 5 6 7 8 9 10 FITNESS/MOVEMENT/TRAINING: What's your activity level? * - Sedentary less than 5,000 steps per day and not much training - Moderately active (5-7,000 steps per day and train 3-4x/week) - Highly active (7-10,000+ steps per day or work a physically demanding job and train 5+ days/week) What do you do for work? Would you describe it as a relatively sedentary job or a high activity job? * Please describe your current training routine? (include all modalities that you partake in) * MOTIVATIONS & VALUES: One of the things that is really important to me to help my clients not just improve nutrition but feel more comfortable and confident in their lives. One way we do this is by talking about values. I’m going to ask you some questions now that might help you understand your values and help me understand who you are as a human :) What motivates you? * What are your non-negotiables? (think of aspects of your life that you prefer not to give up - social events, date nights, family dinners out, etc) * What are the activities and priorities that are taking up most of the space in your life right now? * If you were to look back on your life 10, 15 or 20 years from now, what qualities would you feel proud to say you embodied or focused on in your life? How would you like people to describe you? * What are your current goals or what are you looking to achieve in coaching? How would achieving these things align with your values? * In what ways do you feel you’re already acting.living in alignment with your values? * In what ways do you feel like you’re not acting or living in alignment with these values? * What, if anything, keeps you from those goals/values at the moment? Share any insight you might have here! * STRESS & SLEEP: How would you describe your quality and quantity of sleep on average? * Do you have a consistent bedtime and wake-up time? * On a scale of 1-10, how would you rate your current stress levels on a daily basis? * 10 being the highest How does your sleep affect your daily energy levels and mood? * What are the primary sources of stress in your life? * How do you typically manage stress? * How effective do you find these stress management techniques? * OTHER: Have you ever worked with a nutrition coach before? If so, how was that experience? * What is your reasoning for wanting to work with me as your coach? * Where did you hear about A-Hub Nutrition? * What do you expect from me as your coach? * What can I expect from you in this coaching relationship? * The expectation is you'll check-in every week, even if you had an off week or "messed up". We want you showing up for yourself even when you're discouraged. How does this make you feel?: * If you miss a check-in without a heads up, how would you like me to respond?: * Thank you!
