Nutrition and Fitness Programming Intake Form Name * First Name Last Name Email * Gender Male Female Age Height Feet and inches Activity Level Sedentary (office job, rarely exercise) Light Exercise (1-2x per week) Moderate Exercise (3-5x per week) Heavy Exercise (6-7x per week) Body Fat % (If unsure, leave blank) Health Goals What are your health goals that you plan to work towards using this programming? Please be specific here. Think “I want to lose 20 pounds over the next 5 months while preserving / building muscle” or “I would like to work towards ~15% body fat” instead of “be healthier and look better." Nutrition Habits Of the foods below, indicate whether you like them, dislike them, or are indifferent. I would pick indifferent if you have this reaction to a food - “I got nothing against ya green beans, and would certainly eat you if you were put on my plate, but I don’t exactly get excited when I see you on a menu.” The more selective you are with your “likes,” the more customized your program will be to the foods you enjoy the most. Cereal Like Indifferent Dislike Bagels Like Indifferent Dislike Pancakes Like Indifferent Dislike Waffles Like Indifferent Dislike Bread Like Indifferent Dislike Smoothies Like Indifferent Dislike Pizza Like Indifferent Dislike Pasta Like Indifferent Dislike Sandwiches Like Indifferent Dislike Ice cream Like Indifferent Dislike Cookies Like Indifferent Dislike Candy Like Indifferent Dislike Dark chocolate Like Indifferent Dislike Protein bars Like Indifferent Dislike Protein shakes Like Indifferent Dislike Beef jerky Like Indifferent Dislike Chips/Crackers Like Indifferent Dislike Animal Proteins - Eggs Like Indifferent Dislike Eggs Whites Like Indifferent Dislike Bacon Like Indifferent Dislike Turkey Bacon Like Indifferent Dislike Sausage Like Indifferent Dislike Turkey Sausage Like Indifferent Dislike Chicken Sausage Like Indifferent Dislike Ground Beef Like Indifferent Dislike Steak Like Indifferent Dislike Ground Chicken Like Indifferent Dislike Chicken Breast Like Indifferent Dislike Chicken Thighs Like Indifferent Dislike Ground Turkey Like Indifferent Dislike Roasted Turkey Like Indifferent Dislike Pork Like Indifferent Dislike Ground Pork Like Indifferent Dislike Salmon Like Indifferent Dislike Tuna Like Indifferent Dislike Shrimp Like Indifferent Dislike Crab Like Indifferent Dislike Sea Bass Like Indifferent Dislike Halibut Like Indifferent Dislike Swordfish Like Indifferent Dislike Cod Like Indifferent Dislike Dairy - Milk Like Indifferent Dislike Yogurt Like Indifferent Dislike Cottage Cheese Like Indifferent Dislike Feta Cheese Like Indifferent Dislike Swiss Cheese Like Indifferent Dislike Cheddar Cheese Like Indifferent Dislike Mozzarella Cheese Like Indifferent Dislike Parmesan Cheese Like Indifferent Dislike Cream Cheese Like Indifferent Dislike Butter Like Indifferent Dislike Whey Like Indifferent Dislike Blueberries Like Indifferent Dislike Strawberries Like Indifferent Dislike Raspberries Like Indifferent Dislike Blackberries Like Indifferent Dislike Bananas Like Indifferent Dislike Apples Like Indifferent Dislike Oranges Like Indifferent Dislike Mango Like Indifferent Dislike Peach Like Indifferent Dislike Pears Like Indifferent Dislike Pineapple Like Indifferent Dislike Watermelon Like Indifferent Dislike Grapes Like Indifferent Dislike Grapefruit Like Indifferent Dislike Cantaloupe Like Indifferent Dislike Cherries Like Indifferent Dislike Avocado Like Indifferent Dislike Vegetables - Broccoli Like Indifferent Dislike Cauliflower Like Indifferent Dislike Brussel Sprouts Like Indifferent Dislike Asparagus Like Indifferent Dislike Bell Peppers Like Indifferent Dislike Mushrooms Like Indifferent Dislike Onions Like Indifferent Dislike Tomatoes Like Indifferent Dislike Carrots Like Indifferent Dislike Corn Like Indifferent Dislike Cucumber Like Indifferent Dislike Pickles Like Indifferent Dislike Spinach Like Indifferent Dislike Arugula Like Indifferent Dislike Kale Like Indifferent Dislike Potatoes Like Indifferent Dislike Sweet Potatoes Like Indifferent Dislike Legumes - Green Beans Like Indifferent Dislike Beans Like Indifferent Dislike Peas Like Indifferent Dislike Chickpeas Like Indifferent Dislike Lentils Like Indifferent Dislike Edamame Like Indifferent Dislike Healthy Fats and Oils - Extra Virgin Olive Oil Like Indifferent Dislike Avocado Oil Like Indifferent Dislike Nuts and Seeds - Peanuts Like Indifferent Dislike Almonds Like Indifferent Dislike Pistachios Like Indifferent Dislike Cashews Like Indifferent Dislike Walnuts Like Indifferent Dislike Hazelnuts Like Indifferent Dislike Macadamia Nuts Like Indifferent Dislike Pumpkin seeds Like Indifferent Dislike Sunflower seeds Like Indifferent Dislike Chia seeds Like Indifferent Dislike Flax seeds Like Indifferent Dislike Whole Grains - Oats Like Indifferent Dislike Rice Like Indifferent Dislike Farro Like Indifferent Dislike Quinoa Like Indifferent Dislike Popcorn Like Indifferent Dislike Vegetarian / Other Plant Proteins - Eggplant Like Indifferent Dislike Falafel Like Indifferent Dislike Tofu Like Indifferent Dislike Tempeh Like Indifferent Dislike Do you have any dietary restrictions or allergies? If you already addressed this based on your dislike choices, just put N/A. How many meals per day do you usually eat? 2 3 4 Do you like to snack? Yes No Do you like dessert? Yes No Which fast casual restaurants do you most regularly eat at? Pick up to 3. Dos Toros Chipotle DIG Sweetgreen Just Salad Salad Works Chop’t Cava Shake Shack Halal Guys Jersey Mike’s Playa Bowls Panera Bread Other Other 2 Other 3 Please include any other important information relevant to nutrition that might be helpful to keep in mind as I build your program. Do you drink alcohol? Yes No Exercise Habits - Do you have any current injuries or limitations? What's your favorite form of exercise? What is your current exercise routine? Do you have access to a gym with weights? How many times per week do you currently implement a resistance / strength training program (i.e. lift weights)? 0 1-2x 3-4x 5x+ How would you describe your current strength training experience? Beginner Intermediate (have routinely lifted weights over the years but could have a more structured plan) Advanced (have implemented a focused weightlifting routine for years with an emphasis on progressive overload) Expert (compete professionally) How many days per week are you willing to commit to lifting weights in a gym with full equipment as part of this program? 0 1 2 3 4 5 6 Please include any other important information relevant to exercise that might be helpful to keep in mind as I build your program. Thank you! I'll reach out to you shortly.
