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Intake Form for Nutrition by Babz
First Name
Last Name
Email Address
Phone Number (if non-US phone number, please include country code)
Form Questions
What is your height (in inches)?
What is your weight (in pounds)?
Goal Setting: Here is a list of common nutrition/fitness goals. Please rank your top 3 or 4. Feel free to add something to your list. 1) Fat Loss 2) Improved health/wellness 3) Improved relationship with food 4) Improved performance 5) Increase muscle mass 6) Sport specific 7)Weight gain
If you ranked Sports Specific as one of your TOP 3 GOALS please select yes to this question and answer the next 3 Sport Specific questions.
Yes
No
Sport Specific Question (Skip if not one of your top 3 goals): What type of sport do you participate in?
Sport Specific Question (Skip if not one of your top 3 goals): Are you currently training for anything specific like a competition? If so, please provide details on the kind of competition and important dates.
Sport Specific Question (Skip if not one of your top 3 goals): Does your sport utilize weight class specifications? If so, what is your weight class?
Goal Timeline: Is there a specific timeline in which you would like to achieve the top 3-4 goals that you listed above? Achieving goals takes time, I am here for you to discuss what might be a reasonable time frame for you. However, if there is a specific date in which you are aiming to achieve your goal I would like to know. For example, a wedding, a competition or a vacation.
Which type of progress is more important to you? Immediate progress that is more difficult to maintain or Sustainable progress that is easier to maintain and may not be seen quickly
Are there any specific milestones you are hoping to achieve? Examples can be fitness, nutrition or lifestyle related (ex. Strict pull up, lose 5lbs, cook more).
What is your most persistent nutrition/fitness related obstacle?
Nutrition Specific: Before you decided to make this change, what did a typical day of nutrition look like? Please make sure to not “sugar coat” your response. We are looking for an honest and real representation of your intake. If possible, include total calories, carbs, protein and fats. If unknown, list your food intake (type and amount) for a typical day.
How often are you making trips to the grocery store or getting groceries delivered? 1) Rarely or Never 2) 1x per month 3) 1x per week or more
How often are you eating at restaurants or outside of your own home? 1) Rarely or Never 2) 1x per month 3) 1x per week 4) More than 1x per week
Which of the following best describes how you feel about cooking your own food? 1) I love cooking and do it frequently. 2) I cook often but don’t enjoy it or feel confident in my abilities. 3) I rarely cook (either dislike it or prefer convenience).
Do you currently prepare any of your food for the week ahead of time? 1) None 2) 1-3 Meals per week 3) 4-7 Meals per week 4) 8 or more meals per week
Do you have any allergies or dietary preferences? This can give me a better idea of things you're staying away from which helps me determine what food or supplements can be recommended (ex. Vegan, vegetarian, paleo).
Do you prefer/enjoy foods that are higher in fat or higher in carbs?
How often do you drink alcoholic beverages per week? 1) Never or rarely 2) 1x per month 3) 1x per week 4) More than once per week
Have you ever weighed and measured your food using a food scale?
Yes
No
If you answered yes to the last question. How confident do you feel in weighing and measuring your food? 1) I am very experienced 2) I feel relatively confident but still get frustrated 3) I find it very overwhelming
Have you ever used a food tracking app before? (example - MyFitnessPal, MyMacros+)
Yes
No
Do you use any supplements or medications (including birth control)? If so, please list all that you use.
When you look at a food item would you know if it consisted primarily of carbs, fats or protein?
Yes
No
Fitness/Lifestyle: Which of the following best categorizes your style of exercise? Type any that apply. - Resistance Training (example - lifting weights) - High Intensity Cardio - Sport Specific Work - Low Intensity Cardio (example - walking) - Other (please specify)
How often do you workout in a typical week? *Please refrain from any “sugar coating” we are looking for complete honesty here so we can support you best. 1) Rarely or Never 2) 1 - 3x per week 3) More than 3x per week
If you answered “More than 3x per week,” how many days per week exactly?
What is the activity level of your occupation? 1) None 2) Moderate 3) High (Explain if necessary)
What does your work/school schedule look like? 1) Day 2) Afternoons 3) Nights 4) Shift work
Are you the primary caregiver in your household? This includes children, individuals with disability or elderly relatives.
How often do you travel? 1) Never or Rarely 2) 1x per month 3) 1 - 3x per month 4) 1x per week or more
How many hours of sleep opportunity do you give yourself on a typical night (how long are you in bed)? 1) Less than 5 - 6 2) 7 - 8 3) 9 or more
How would you rate your sleep quality from 1 - 10 (10 being best)? Explain why you gave the rating.
When it comes to following a nutrition/fitness program how much support do you have? Please type the number of the one that most closely applies to you. 1) Majority of the people in my life are very supportive. They are either also into health and fitness or help me when I struggle and don’t pressure me to break the commitments that I have made. 2) I have a few people that join me in health and fitness or support me in my goals. However, there are a few people who don’t understand why I want to change - these people don’t eat healthy, rarely exercise and/or drink frequently. 3) I have very few people in my life that are supportive of the goals I want to achieve. Most of the people in my life are not eating healthy, exercising and/or drink frequently.
In the past what nutrition approach has worked best for you to achieve your goals? Type of approach. Describe if necessary. Examples might be counting macros, eating "clean", weight watchers, etc.
Pros and Cons of that method?
Do you or have you ever suffered from any medical illnesses?
Yes
No
If yes, what was the treatment and are you still undergoing treatment or taking medication for it?
Do you or have you ever suffered from any type of eating disorder?
Yes
No
If yes, what was the treatment and are you still undergoing treatment for it? When was the last episode?
Are you pregnant? Knowing this helps us evaluate your situation better as there is now more than just yourself to consider.
Yes
No
Have you given birth in the past six months?
Yes
No
Pregnancy Follow Up Questions (Answer if you selected yes to either of last two pregnancy questions): What was your pre-pregnancy weight?
Pregnancy Follow Up Questions: What is your estimated due date or when did you deliver?
Pregnancy Follow Up Questions: Which number pregnancy is this for you? (First child? Second?)
Pregnancy Follow Up Questions: This question is optional - Do you have a history of pregnancy loss or miscarriage?
Pregnancy Follow Up Questions: Have you experienced a history of depression or anxiety?
Pregnancy Follow Up Questions: Did you have any complications with a previous pregnancy (gestational diabetes, premature birth, pre-eclampsia,etc)?
Pregnancy Follow Up Questions: Do you have anyone on your pregnancy/birth team (OB, midwife, doula, chiropractor, coach, counselor)?
Pregnancy Follow Up Questions: Are you currently breastfeeding? Or have you been breastfeeding in the past six months?
Yes
No
Breastfeeding Follow Up: How much longer would you like to breastfeed?
Breastfeeding Follow Up: Have you struggled at all with your milk supply?
Is there anything else you would like your coach to know about you?
How did you hear about Nutrition by Babz?
Are you a member of a gym? If so, what's the name of it?
If you are a member of CrossFit G6 - how long have you been a member?
Have you done nutrition coaching with me before?
Yes
No
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