Name

First Name

Last Name

Gender

Male

Female

Other

Birthday

YYYY

Age:

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Cell:

(###)

###

####

Occupation:

Marital Status:

Do you have any children? If so, how many?

Referred By:

Health and Wellness Goals

What brings you to reach out for a nutritional consultation?

What are your SHORT term goals & expectations?

What are your LONG term goals & expectations?

What are your main areas of concern, in order of importance?

Please list at least 3

How have you dealt with your main areas of concern in the past?

Doctors

Self Care

Have you previously utilized nutritional or lifestyle protocols for the betterment of your health and wellness? If so, what were they and what were your results?

Are you currently working with any other health practitioners?

Yes

If yes, please list who and for what assistance:

Are there any obstacles or challenges that you believe may make it difficult to achieve your goals?

On a scale of 1-10, how likely are you to commit to a long term journey in order to reach your goals?

1 being not very adherent, 10 being very adherent

Are you looking for a short term fix or a long term solution?

Are you someone who needs constant check-in and analysis in order to stay on task and motivated?

On a scale from 1-10, how motivated are you towards achieving your goals?

1 not very much, 10 very much so

Health History

Your usual health is:

Relevant specifics or other medical history items:

Reproductive Health

Fill out as applicable

Do you have regular periods?

Yes

Do you experience any PMS symptoms?

Yes

Are you taking birth control?

Yes

Have you reached menopause?

Yes

Medications & Supplements

Please list any over the counter pharmaceuticals, prescriptions, supplements, herbs, vitamins etc that you take:

Name, duration, dosage and for what reason?

Have you recently taken or when did you last take antibiotics?

Please list any surgeries or hospitalizations.

Date, description:

Stress

What is your current stress level?

Low

Medium

High

When is your energy at its best?

When is your energy at its worst?

Digestion

How often do you have a bowel movement?

Describe your bowel movements:

Hard and small

Loose and watery

Soft and well formed

Do you suffer from any of the following?

Gas

Bloating

Cramping

Constipation

Diarrhea

Nutrition & Lifestyle

Height (ft):

Weight (lbs):

Do you have a weight goal (lbs)?

Any recent changes or fluctuations in weight?

Have you ever been on a restricted diet? If so which one(s) and when?

Are you currently following a specific diet?

Paleo

Gluten Free

Dairy Free

Vegetarian

Vegan

Keto

Raw

Other (specify below)

Are there any food groups you avoid?

Do you have any known food allergies?

How much water do you consume each day?

What other beverages do you typically consume?

Do you drink coffee?

Yes

How much each day?

Do you eat breakfast?

Yes

If yes, what would a typical breakfast look like for you?

How often do you eat out at restaurants or order takeout?

How often do you eat packaged or frozen foods?

How often do you eat canned food?

If relatively often, what types of canned foods?

Who in the household typically does the food shopping?

Do you drink alcohol?

Yes

How often?

Do you smoke (cigarettes, marijuana, cigars)?

Yes

How often?

Are you familiar with how to read and understand food labels?

Yes

Not Sure

Do you often feel hungry?

Yes

If yes, when?

How many hours of sleep do you get each night?

Do you wake feeling rested?

Do you wake feeling hungry?

Are there any foods that you avoid because of the way that they make you feel?

Are you aware of any delayed symptoms after eating certain foods? (ex - fatigue, bloating, gas, hives, sinus congestion etc.)

What foods do you typically crave?

Sweet

Salty

Bread/Pasta

Caffeine

Other

Which of the following foods/beverages do you consume regularly?

Soda

Refined Sugar

Diet Sodas

Alcohol

Fast Food

Gluten (wheat, rye, barley)

Dairy

Coffee

Describe what a typical week of exercise looks like:

Day of the week, duration, intensity, etc.

What do you typically eat before training? How many hours/minutes before?

Do you eat during training? If so, what?

What do you typically eat after training? How many hours/minutes after??

Indicate all that apply to your current state of being, lifestyle, and eating habits.

Eat too much

Erratic eating patterns

Late night eating

Fast eating

Often skip meals

Afternoon fatigue

Frequent colds/illness

Do not plans meals/eat on the run

Other (specify below)

Is there anything else you would like me to know about your current diet, history or relationship to food?

Action Item:

Please complete a detailed 3-day food log for me to review. Do this via My Fitness Pal; you can set up a free account. After your 3 days of food logging, please email me your login username and password. It is really important that you don’t alter or change your food habits when you do this - I look at food logs without judgment! Remember that we cant address any issues if I don’t know or see what they might be :)

Informed Consent

Nutrition and exercise are intended to promote general health and wellness and are not intended to replace medical care. All nutritional assessment, suggestions and consultation on nutrition, diet, and exercise are based on your input and are not intended to diagnose, treat, or cure any disease or ailment. Results and changes in your general health and wellness may vary depending on medical conditions, medications and accuracy in following suggested guidelines. Never reduce or eliminate physician prescribed medications without the direction of a medical care provider. I confirm that all the information I have given is true and to the best of my knowledge. I understand that Jen Segger (as Challenge by Choice Training Systems, JLS Training Systems Inc) is not a registered dietician and can only help guide you as it relates to overall health and wellness, and to support your athletic goals.

Signature

First Name

Last Name

Date

YYYY

Thank you! Jen will be in touch shortly to get you rolling with your Training Plan.