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Nutrition Intake Form

If you'd like to get started on a nutrition plan with me, please fill out the following form to get started!

Nutrition Intake Form

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First Name

Last Name

Email Address

Phone Number

What’s motivating you? Why are you wanting to do this now?

Do you have an amount of weight you want to lose and a time frame?

Are you willing to mark your progress and track your food intake?

How many meals and snacks a day do you currently eat?

What percentage of the above are prepared at home?

Have you lost and gained more than 5 to 10 pounds in the past?

How many times have you dieted in the past 10 years?

Are you able and willing to spend a few hours a week preparing meals and planning for healthier options?

Are you also interested in guidance with an exercise plan?

Any other comments?

Remember when crossing the monkey bars was easy? Get strong at ANY age, add definition to your body, and get lean. Life is a playground. Come play with us!

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