NUTRITION COACHING APPLICATION

Full Name

First Name

Last Name

Email Address

Phone Number

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Age

Height

Weight

specify pounds or kilos

Body Fat Percentage

Describe your nutrition history, as well as your current nutritional habits.

Are you taking any medications and/or supplements? If so, what are you taking, how much are you taking, and how often are you taking it?

Describe your sleep. How is the quality? The quantity?

Describe your stress levels.

Describe your specific goals.

Why are these goals important to you?

What have you tried in the past (diets, changes, etc.)?

What are your obstacles? What do you feel has kept you from succeeding?

Why have you decided to seek out a coach? What are you expecting out of a client-to-coach relationship?

On a scale of 1-10, how committed are you to reaching your goals?

1 = If I reach my goal in 3 months, or 5 years, it really doesn't matter. I'd rather spend my time and energy on other things in life even if it means putting my health and fitness on the backburner. 10 = I want to reach my goals as soon as I can. I will eat chicken and broccoli all day long if I have to. I will do anything it takes to reach my goals.

Are there any events in your schedule that will cause you to travel?

Are there any reasons nutrition may be interrupted in the near future?

What are your hobbies/interests?

Who is your favorite superhero?

How did you hear about Poehlmann Fitness?

Please provide any additional information you think we need to know.