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Day

Year

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Company name

Position

What is your main reason for seeking nutrition coaching right now?

How would you rate your average daily energy levels?

Constantly exhausted, dragging myself through the day.

Decent morning energy, but I crash hard in the afternoon.

Steady and reliable energy most of the day.

Describe your sleep. (Check all that apply)

I struggle to fall asleep

I wake up frequently during the night

I sleep 7–8 hours but still wake up tired

I sleep deeply and wake up feeling refreshed

How many cups of water do you drink on an average day?

What does a typical day of eating look like for you? (Briefly list what you usually have for Breakfast, Lunch, Dinner, and Snacks)

Do you experience any of the following after eating? (Check all that apply)

Intense Bloating or Gas

Heartburn or Indigestion

Extreme Fullness or Sluggishness

None of the above

How would you describe your current relationship with food?

I love food but struggle with portion control or making healthy choices

I feel trapped in an "all-or-nothing" cycle (eating perfectly vs. overindulging)

Food causes me anxiety, guilt, or stress

I eat mostly out of convenience, boredom, or stress

Who manages the grocery shopping and cooking in your household?

What is your biggest daily roadblock to eating well?

Time constraints (too busy to cook or prep)

Lack of ideas (bored of the same foods / don't know what to make)

Social pressures (eating out often, family preferences)

Emotional or stress eating

How do you naturally move your body during the week? (e.g., walking the dog, desk job, yoga classes, etc.)

What are your health goals with nutrition coaching in the next 3 months?

On a scale from 1-10 {1 being least ready) how prepared are you to make changes to your food intake and daily routine?

By clicking "Submit" below I acknowledge and understand that:

My nutrition coach is a general wellness professional. They are not a registered dietitian, medical doctor, or licensed therapist. The information, suggestions and meal concepts provided during coaching are for educational, informational, and motivational purposes only. They do not constitute medical diagnosis, treatments, or cure for any physical or mental condition. I am encouraged to consult with my primary healthcare provider before making any drastic changes to my diet, exercise routine, or lifestyle; especially if I have pre-existing medical conditions or take prescribed medications. I assume full responsibility for my health choices and any outcomes resulting from the implementation of wellness strategies discussed during coaching.

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