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!

Describe your job / lifestyle *

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 *

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. *

Do you feel like your eating habits are negatively affecting how you look, feel or perform? *

Yes No Maybe

If you are taking any medicinal drugs, nutritional supplements/Vitamins, etc., please list them here. Why do you take them? Who recommended them? *

What 5 of these goals are most important to you? *

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

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. *

I AGREE

NUTRITION INTAKE FORM

Get Social!

Closer Than You Think!

Let's chat!