Strong Start Nutrition & Fitness Intake Form

Once this is filled & your plan has been purchased, I will start creating your program!

First name

Last name

Email

Phone

Date of Birth

Current Weight

Occupation/Daily Movement Level

What are your top 1–3 health, fitness, or body composition goals?

What does "success" look like for you in 3 months?

What has held you back from achieving these goals in the past?

On a scale of 1–10, how committed are you to change right now? (1 = Not ready, 10 = All in)

Describe your typical eating patterns across the past 6 months. (Include any patterns like skipping meals, snacking often, emotional eating, frequent takeout, binging, etc.)

How many meals do you eat per day on average?

Do you currently track food intake?

Yes, Daily

Occasionally

No

Do you follow a specific dietary style? (e.g., vegetarian, intermittent fasting, keto, intuitive eating, etc.)

Do you have any food allergies or sensitivities?

Are there any foods you avoid for personal, ethical, or digestive reasons?

This is a checkbox.

How often do you experience the following? Bloating:

Rarely

Sometimes

Often

Fatigue after meals:

Rarely

Sometimes

Often

Digestive discomfort (gas, constipation, etc.):

Rarely

Sometimes

Often

How much water do you drink daily?

How many alcoholic drinks do you consume per week (if any)?

On average, how many times per week do you: Eat out / Takeout: Consume processed snacks or desserts: Eat home-cooked meals:

Are you currently exercising? If yes, describe your routine (type, frequency, intensity).

What is your experience level with strength training?

Beginner

Intermediate

Advanced

Any injuries, limitations, or pain I should be aware of?

How many days per week are you realistically willing to train right now?

Do you have access to a gym or workout equipment at home?

How would you describe your energy levels throughout the day?

How many hours of sleep do you get per night (on average)?

Do you wake up feeling rested?

What are your biggest daily stressors right now?

What helps you regulate stress (if anything)?

Do you currently take any supplements or medications?

Is there anything else you’d like to share about your health or history?