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HELLO AND WELCOME!
Thank you for choosing to working with myself. To get things rolling I would be grateful if you could fill in the information asked below. This helps me get a good understanding of your current fitness level, goals, diet and generally a bit about you.
The more information you can supply the better I can make our system more personalised for you and in order to create a great nutrition program.
All information given is kept confidential and I request that the information supplied is used solely by you and is not shared.
The consultation is split into four sections; Nutrition Analysis, Physical Training Analysis, Pictures & Food Diary. Please fill in all sections before returning the package. You may wish to print this off to complete it; I can supply an address to send it to if required. Answer the questions truthfully and accurately. There is a goal-setting question for each section. Adding facts and figures to this goal will help you track your progress and evaluate the results. We can also review your goals and provide the relevant and correct advice.
Use the
SMART
principle when setting goals. This is;
Specific
– What exactly do you want to achieve using this plan? E.g. 6lb weight
Measurable
– What methods can you use to record progress? E.g. scale weight/Mirror
Actionable
– What do you believe is required to achieve your goal? E.g. better food choices
Realistic
– Can you achieve this goal, even with help? What might hold you back?
Time frame
– By when do you want to achieve your goal?
!Please remember to save any changes made before exiting the document!
The more information you can supply the better I can make our system more personalised for you and in order to create a great nutrition program. Please fill the pack with an open and honest mind. I am 100% non-judgemental.
PERSONAL DETAILS
CONTACT INFORMATION
Name
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Phone Number
*
Email
*
Age
*
Scale Weight (KG)
*
Height (In cm)
*
Where Did You Hear About Us?
*
How Are You Feeling Right This Minute?
*
How Healthy Do You Currently Feel?
*
Please Describe Your Current Nutrition Knowledge Level
*
NUTRITION ANALYSIS
1. Please describe any previous diets that you have followed, how successful they were and how you felt during them. E.g. Paleo, low carb, weight watchers, intermittent fasting etc.
2. Please describe what your favorite healthy food choices are. Include what your favorite protein; carbohydrate and fat source is E.g. Tuna, Pasta and Eggs.
3. Please highlight any foods you do NOT like:
4. Please describe any allergies and/or intolerances you may have:
5. Are there any other foods to which you’re particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness)?
6. Please describe your current supplements (i.e. protein powder, creatine, vitamins/minerals) intake. If you do not currently take supplements, are you willing to introduce some beneficial ones?
7. Please describe your goals in relation to a nutrition program. Remember to use the SMART (page 1) principle when setting these
8. To date, what is the main factor(s) holding you back from achieving your nutrition goals?
9. Please provide a timetable with your most normal daily schedule, listing the time you wake up, work, have breaks, eat, work out and go to sleep:
10. Do you have any weekly activities that you undertake e.g. Football every Tuesday night?
11. Do you currently take any medication?
12. How do you feel after eating a large carbohydrate meal e.g. bowl of pasta?
13. Do you enjoy eating white or red meats the most?
14. Do you get food cravings, if so, what for?
15. Do you ever binge eat?
16. Would you say you have a good relationship with food?
PHYSICAL ANALYSIS
PHYSICAL TRAINING COVERS ALL ASPECTS OF FITNESS YOU CONDUCT.
1. Please describe what current training/sport you do (if applicable) E.g. Weight Training/Cardiovascular exercise/MMA/rugby.
2. Please describe any current or previous injuries you have obtained that may affect your physical training;
3. Please describe your goals in relation to a physical training program. Remember to use the SMART (page 1) principle when setting these;
4. To date, what is the main factor(s) holding you back from achieving your training goals?
7. Exercise Information - Please rate the ability in the following equipment (check the box that corresponds with your ability;
Dumbbells
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Barbell
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Kettle bell
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Medicine ball
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Bosu ball
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Resistance bands
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Sandbags
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
OLYMPIC MOVEMENTS
Snatch
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
Clean
UNFAMILIAR
NOVICE
INTERMEDIATE
ADVANCED
8. Do you have any Postnatal concerns in relation to yourself or fitness. Example: Do you leak during any impact exercise, coughing, sneezing etc or can’t feel your abdominals working/ can’t do a sit up etc. Please give a detailed answer.
9. If you have been pregnant or given birth, did you have any complications attached to this? Please give a detailed answer.
10. How long ago were you pregnant / gave birth?
11. Have you seen a specialist for any postnatal concern? What was the outcome?
PICTURES
File
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Max. file size: 512 MB.
Up to date pictures are extremely important for creating tailored nutrition plans. This allows me to see your current body type, potential genetics, hormonal profile, postural analysis, body fat distribution and so much more. Please do not skip this section; it can make a huge difference in the output of your nutrition plan which can drastically affect results.
It is best to ask someone to take these pictures to ensure good quality and full body shots. A front, side and rear picture is ideal, with men wearing only shorts and women wearing gym vest and shorts.
All information supplied is kept confidential and will never be shared or passed on.
MOTIVATIONAL PICTURES
Most people have a picture of the ideal body they would like to achieve. If you can attach this picture(s) with the E-mail it is great for setting goals and motivation. We can then discuss the strategies and techniques to be used to achieve this look, and then start applying the best processes to get you on the right track. This is also great for setting long-term goals and realistic time frames in order to complete them. This will allow us to program a long-term plan and set time frames for each stage.
FOOD DIARY
It is essential to look at your current nutrition in order to maximize the help I can provide you with and to get the correct starting point for your nutrition plan. By looking at your current diet I will be able to see your current nutrition lifestyle and find any problems within it. I can then tailor your new plan to remove these problems while still respecting your lifestyle so we can achieve your results while making the integration process as easy as possible.
Please detail all food, liquids and supplements that you consume for at least the next 3 days. After 3 days of consistently tracking your food please email me the food diary along with the completed consultation. Only then I can start creating your nutrition pack.
Day 1
Please state the time, meal you had, amount, and any comments about that meal
Date
MM slash DD slash YYYY
TIME + MEAL (Day 1)
FOOD + AMOUNT (Day 1)
COMMENTS (Day 1)
Day 2
Please state the time, meal you had, amount, and any comments about that meal
Date
MM slash DD slash YYYY
TIME + MEAL (Day 2)
FOOD + AMOUNT (Day 2)
COMMENTS (Day 2)
Day 3
Please state the time, meal you had, amount, and any comments about that meal
Date
MM slash DD slash YYYY
TIME + MEAL (Day 3)
FOOD + AMOUNT (Day 3)
COMMENTS (Day 3)
FINALLY!
Thank you for completing the consultation process, this greatly benefits me for creating your nutrition and training plan, getting to know you and provide you with the best advice and support. It has encouraged you to think hard about your goals, were you currently stand in achieving these and how to achieve them. By doing so you have already completed one of the main hurdles that face people when trying to achieve their ideal body and health.