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NUTRITION INTAKE FORM
This intake form is nutrition coaching specific, and meant to build on the general intake form. That said, some questions are carried over from the general intake form for clarity and to consolidate nutrition-relevant information.
please fill out the form in its entirety. Thanks!
PERSONAL Information
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Indicates required field
Name
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First
Last
Email
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Emergency Contact
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Doctor
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Emergency Phone Number
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Doctor's Number
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Height
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Weight
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What is your Date of Birth?
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Biological Sex
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Male
Female
Other / Prefer not to say
Activity HABITS
Describe your job / lifestyle
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Sedentary Job (e.g. call center, bank clerk)
Busy Job (e.g. Busing tables, line cook)
Physical Job (e.g. labourer, mover)
Retired but active (e.g. chores, gardening, maintenance)
Retired but inactive (e.g. don't leave house much, sit mostly, card games)
Describe your current exercise level
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little or no exercise
light exercise or sports 1-3 hours/week
moderate exercise or sports 3-5 hours/week
hard exercise or sports 5-7 hours/week
hard daily exercise or sports 2x day
Do you find it difficult to do some kind of moderately strenuous, daily physical activity? Explain.
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Eating Habits
Are you here for weight loss?
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Yes
No
Maybe
If "Yes", have you had success with weight loss before? Explain.
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Are you here for muscle gain?
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Yes
No
Maybe
If "Yes", have you had success with muscle gain before? Explain.
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Are you here for better strength/power/sports performance?
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Yes
No
Maybe
If "Yes", list your "PR's" and/or accomplishments in your sport of interest.
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Do you feel like your eating habits are negatively affecting how you look, feel or perform?
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Yes
No
Maybe
If "YES", explain. If "MAYBE", why didn't you answer "YES"?
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If you are taking any medicinal drugs, nutritional supplements/Vitamins, etc., please list them here. Why do you take them? Who recommended them?
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This is important for several reasons: negative side effects that may endanger you or others during class; some supplement ingredients are on the WADA banned list; some supplements are a waste of money and I can tell you which ones and why
GOALS & EXPECTATIONS
What 5 of these goals are most important to you?
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Develop sustainable eating habits
Reduce blood pressure, strengthen my heart, improve my overall health
Improve body shape and composition
Regain lost muscle
Increase muscularity
Improve sport performance with professional coaching, and/or better nutrition
Do a bodybuilding / physique / figure competition
Feel better about my self-image
Which goal do you want to achieve first?
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Identify some potential future (or current) obstacles to your goal(s).
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I assure that the information I have provided to be accurate, and that I provide this information freely to Ballistic Strength Nanaimo (the company) so that the company may provide the best service(s) possible based on that information. I do not give the company permission to sell, trade, misuse, manipulate, or release my personal information publicly or privately in digital format or otherwise without my expressed written consent.
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I AGREE
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