Intake Form

Please take a few minutes to fill out this intake form. Be as accurate as possible. I will use the information to build your personalized plan.

First Name

Last Name

Email (used for program accounts and profiles)

Age

Gender

Height

Current Weight

How physically demanding is your job?

How many times per week do you intentionally workout?

What type of exercise do you do? And for how long?

What is you primary goals - weight loss, performace, improved energy?

Do you have any medical conditions that I need to be aware of?

What medications are you currently taking?

Do you have any food allergies?

Do you avoid any specific foods.

Ideally, you should be eating a verity of foods from the food groups. These include, lean protein, whole grains, low-fat dairy, fruits, vegetables, beans, nuts and seeds. Do you current eat from all the food groups? If no, please indicate which one and why.

How many times per week do you go out to eat per week. VS How many times you eat at home.