Complete the following form as truthfully as possible to provide us with information about your current habits and general feeling about health and fitness.
Please share your typical daily food intake. Be very specific and complete. Include the time and what meals, snacks and beverages were consumed. Include any other items you eat such as candy, gum, etc.
Please any medications or supplements you are currently taking, if any. Include over the counter medications like ibuprofen.
Describe changes, if any, that you have made to your eating habits in the past?
Fill in the blanks...
Rate the following questions using 1 as the lowest and 10 as the highest.
What barriers, if any, stand in the way of you achieving your nutritional/health goals?
What are your expectations after completing 12 weeks and how do you define success?
Any additional information you'd like to share?
