Nutrition Coaching Intake Form

Contact information

Your Name

Pronouns
shehetheyherhimother

Date of Birth

Phone Number

Email

Instagram Handle

Occupation

Emergency Contact Name & Phone Number

Nutrition Programs

I am interested in
NourishBoostPerformI'm not sure, advise me!

Medical history

Are you currently taking any medications or health supplements? Please specify type, dosage, and reason for taking.

Do you have any allergies?

Do you have a (family) history of heart trouble, high blood pressure, asthma or diabetes?

Have you been hospitalized for any reason? If so, please explain.

Have you ever experienced any head injuries? (Concussion/physical altercations/contact sports/falls/bicycle accident)? If yes, please explain.

Have you ever experienced any problems with sleep? If yes, please explain.

Have you ever experienced any problems with digestion? If yes, please explain.

Do you have any other medical conditions that have not been mentioned so far?

Health & Nutrition

Why are you looking for nutrition coaching?

Please explain any concerns about your health, eating habits and/or fitness.

What degree of stress are you under on a scale of 1-10 (10 is highly stressed, 1 is not stressed at all)? Why?

Do you take part in physical exercise? If so, what and how often?

Do you currently follow a specific nutrition plan or way of eating? If yes, please explain.

Right now, how would you rank your overall eating/nutrition habits? Why?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body? If so, what?

Which of those things worked well for you (even if you may not be doing them right now)?

Which of those things did not work well for you?

Developing your Nutrition Program

What are your nutrition goals? (ex: lose weight, gain weight, feel better, increase energy, improve understanding of nutrition, improve athletic performance)

How would you like your habits, health, eating and/or body to change?

How long have you been thinking of these goals?

How important are these goals to you?

Until now, what has held you back from these goals?

If you achieved these goals, how would you feel?

Realistically, how much time are you willing to dedicate to this process?

How much time are you able to spend on this process?

What are the best days/times during the week for you to commit to your nutrition coaching program?

Who does the majority of the shopping, food prep and cooking in your household?

Our Coaching Relationship

Why do you want to work with a nutrition coach?

Describe your ideal coaching relationship and what is the coach's role is in your nutrition journey?

How can I help you reach the goals you listed?

What you feel are the obstacles or potential actions, behaviours or activities that could stand in the way of accomplishing your goals?

Anything else you’d like me to know about you? Personality? Needs? Core values? Anything that would help me get a better sense of YOU is encouraged!

Acknowledgment, Participant Release & Cancelation Policy

I understand and agree that it is my responsibility to inform Fit With Lou/Rebel Nutrition of any condition or changes in my health that might affect my ability to complete the program safely.

I agree that Fit With Lou/Rebel Nutrition shall not be liable or responsible for any injuries to me resulting from my participation in the program and I expressly release and discharge Fit With Lou/Rebel Nutrition from all claims, actions or judgments as a result of any injury or damage which may occur in connection with my participation.

I understand that Fit With Lou/Rebel Nutrition operates on a scheduled hourly appointment basis and that I must provide a minimum of 24 hours notice if I need to reschedule an appointment. The ability to reschedule depends on the availability of open sessions in the following 7-day period after the cancelled session. Where less than 24 hours notice is given, I understand that rescheduling will not be possible and I will be charged for the session. My coach will utilize that time to further develop my nutrition plan.

Upon beginning the program, the contract will automatically renew on a month-to-month basis. I agree to give a 30-day notice of cancellation via email to hello@wearerebelnutrition.com in order to cancel the contract.

By signing below, I confirm that all information I submit is correct to the best of my knowledge and that I have read and understood the participant release and cancellation policies.

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