SUSPENDED FORM

Client Name

Client Phone

Client Email

Your Date of Birth

Your Gender

Male‎ Female‎

Height

Weight

Body Fat %
If Known

Please state your current health goals (ex: lose weight, improve blood cholesterol, etc.)

Please provide a detailed account of all foods and beverages consumed in the last 48 hours.

Please describe your current exercise regimen?
Please be as specific as possible. Ex: 30 min high intensity cardiovascular activity daily (trail running or biking)

Please include an example of a basic daily schedule.
Ex: Wake - 6 am, Eat - 6:30 am, Workout - 7 am, Eat 9 am, Work 9 am - 5 pm, Lunch 1 pm, Dinner - 6 pm, Snack - 8 pm, Bed - 9:30 pm.

Please provide 5 staple healthy foods you typically consume each day.

Please provide 5 unhealthy foods you enjoy.

Please select which grocery stores you have available to shop (select all that apply)

Do you have any aversions to any kinds of meats, fish, breads, rice, potatoes, vegetables, fruit, or dairy?
Please list any and all foods that you do not enjoy and/or any known food intolerances or allergies.

Please provide any recent (~1 yr) pertaining lab values, dietary allergy testing information, current dietary supplementation (including vitamins and protein powder), and prescription medication use.

Are you aware of any present hormonal imbalances? If so, please explain hormonal imbalances and treatment if sought out.
Ex: Hypothyroid, Men: Low T, Women: High Estrogen, Low Progesterone, Lack of Regular Menstrual Cycle

Any special dietary needs or circumstances that we should be aware of?

Yes No

Please provide your dieting history.
Ex: history of yo-yo dieting a few times but typically eat whatever, etc.

How do you prefer communication?

Phone Email

More Motivated Than Ever Before
Ready for Change
Somewhat Apprehensive

Please rank your current motivation.

Please note, by clicking "yes," you acknowledge that you understand that our nutrition services are not intended to diagnose, treat, cure, or prevent any disease. Functional Fueling Nutrition, LLC will not be held liable for failure to diagnose or treat any illness, nor will they be liable for failure to prevent future illness. Please consult with your physician before beginning any nutrition plan and/or dietary supplementation

I agree to the terms of service.