Client Information Sheet
Please complete this information sheet and submit to Nutracoach at least
one week prior to your appointment.
here for a printer friendly version of this form.
Do you have a specific question regarding nutrition?
What are your primary health goals?
Are you currently taking any medication/supplements?
What type of exercise regime do you follow?
Last Medical Exam/Physical Date:
Any other medical conditions?
Are you allergic to any foods? If so, which ones?
Types of Food/s Enjoyed
Types of Food Disliked
Main Source/s of Carbohydrates
Main Source of Protein
Main Source of Fats
Would you take supplements? Yes
Please begin a food diary 72 hours prior to your appointment.
The food diary
must include EVERYTHING you consume (please be honest!) this
meals, beverages, snacks, vitamins, medications and number of
hours slept each
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