Nutrition Coaching - Step 1 of 3Personal InformationName *Phone *Email *Gender *MaleFemaleOtherHeight *Weight *DOB *Age *NextCUSTOM BUILT NUTRITION Describe Your Daily ActivitiesWould you describe yourself as: *SEDENTARY - Spend most of the day sitting (bank teller, desk job)LIGHTLY ACTIVE - Spend a good part of the day on your feet (teacher, salesman)ACTIVE - Spend a good part of the day doing physical activity (waitress, mailman)VERY ACTIVE - Spend most of the day doing heavy physical activity (construction, carpenter)Exercise OutputHow many days per week do you exercise? *How many minutes per day do you exercise (including cardio)? *Set Your GoalDo you want to: *Lose WeightMaintain WeightGain WeightIf you selected LOSE WEIGHT or GAIN WEIGHT, how would you like to approach your goal...? *CAUTIOUS (Lose or Gain 0.5lbs per week)NORMAL (Lose or Gain 1lb per week)AGGRESSIVE (Lose or Gain 2 lbs per week)Select Your FoodsDo you prefer: *STRICT DIETING (Clean foods only, much more effective)FLEXIBLE DIETING (Clean foods and your favorite foods, still effective but less effective than strict dieting)Do you prefer Vegan, Vegetarian, Pescatarian, or any other kind of diet? *Would you prefer intermittent fasting? *What are your favorite "CLEAN" foods? *Carbohydrate? (ex: Rice, potatoes, vegetables, fruits, bread, pasta, etc.)Protein? (ex.Chicken, fish, lean ground turkey, lean ground beef, eggs, etc.)What are you favorite “FLEXIBLE” foods? *Store-bought snacks? (ex. Eggo waffles, Pop tarts, popcorn, pretzels, etc.)Restaurant/Fast Food meals? (ex. In-n-out-Combo #1, Chili’s-California Turkey Club, Starbucks-Bacon, Gouda & Egg Breakfast Sandwich, etc.)Drinks? (ex. Grape Juice, Sprite, Arizona Sweet Tea, etc.)Food Allergens? *LifestyleHow many hours do you sleep at night? *What time of day do you workout? *Do you take any naps? *How many times would you like to eat per day? *PreviousNextHEALTH QUESTIONNAIRE / LIABILITY WAVIEREmergency ContactName *Relationship *Phone *Physical Activity Readiness Questionnaire (PAR-Q)Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *YesNoDo you feel pain in your chest when you perform physical activity? *YesNoIn the past month, have you had chest pain when you were not performing any physical activity? *YesNoDo you lose your balance because of dizziness or do you ever lose consciousness? *YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity? *YesNoIs your doctor currently prescribing any medication for your blood pressure or for a heart condition? *YesNoDo you know of any other reason why you should not engage in physical activity? *YesNoOccupational QuestionsWhat is your current Occupation? *Does your occupation require extended periods of sitting? *YesNoDoes your occupation require extended periods of repetitive movements? *YesNoIf yes, please explain *Does your occupation cause you anxiety? (mental stress) *YesNoRecreational QuestionsDo you partake in any recreational physical activities (golf, tennis, skiing, etc.)? *YesNoIf yes, please explain *Medical QuestionsHave you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? *YesNoIf yes, please explain *Have you ever had any surgeries? *YesNoIf yes, please explain *Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension, (high blood pressure), high cholesterol or diabetes? *YesNoIf yes, please explain *Are you currently taking any medication? *YesNoIf yes, please explain *Best Date / Time to CallDateTimeMessageSubmit