Nutrition Coaching - Training Day Cafe

Our approach is to look at the whole person, body, mind and spirit because we are all biochemically distinct. Our goal is to educate people to look at food first to balance their body’s systems. Together we will:

Document your goals, needs and plans
Evaluate your food selection, lifestyle and use of dietary supplements
Help you identify your nutritional imbalances
Implement a personal nutrition plan that can help you achieve your personal goals.

Together, we will look “holistically” at all areas of your life and see what needs support, create a plan of action and let the growth begin. We examine the unique perspective of your life and reveal anything that has been standing in the way of living to your highest potential.

WHAT WE CAN HELP WITH:

Emotional eating / stress eating
Chronic dieting, weightloss
Food allergies and sensitivities
Hormone balance and blood sugar balance
Managing symptoms through a tailored, health-supportive diet
Transitioning into a healthier lifestyle and getting more variety in your meals
Better communicating with your health care team and understanding doctor recommendations

Thank you for your interest in working together. I invite you to fill out this no obligation application and, if it’s a good fit, I will be in touch within 3 business days to schedule a call and chat more.

First and last name & any nicknames you prefer:

Birthday:

Email

Phone Number

Height

Weight (lbs)

Gender:

Male
Female
Prefer not to answer

Age

Occupation:

What does your typical work hours/week look like?

What is your purpose for filling out this form today?

What are your main health concerns/complaints? Please list in priority.

HEALTH & MEDICAL HISTORY

Do you have any medical conditions? (e.g. diabetes, high blood pressure, PCOS, thyroid conditions, etc.)

If yes, please list:

Do you have any food allergies or intolerances?

If yes, please list:

Are you currently on any medications or supplements?

If yes, please list:

Have you recently had any lab work or diagnoses that may impact your nutrition (e.g., iron deficiency, cholesterol levels, blood sugar)?

If yes, please explain:

LIFESTYLE & ACTIVITY

How active are you on a typical day?

What type of exercise do you currently do (if any)?

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

How would you rate your stress levels?

Low
Moderate
High

What level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high):

Do you use any coping mechanisms?

NUTRITION & HABITS

Do you have any dietary restrictions or preferences?

(e.g. vegetarian, keto, dairy-free, halal, etc.)

How many meals per day do you typically eat?

Do you skip meals often?

Yes
No

Do you drink coffee or tea?

If yes, how many cups/day and what do you add (cream, sugar, etc.)?

Do you consume alcohol?

If yes, how often?

On a typical day, what does your food intake look like?

Give an example of what you ate yesterday or on a regular weekday

Do you have any binge-eating or emotional eating patterns you'd like to share?

If yes, please describe briefly:

PROGRAM GOALS & EXPECTATIONS

What are your primary goals for this program?

e.g. weight loss, more energy, better digestion, muscle gain, consistency, etc.

What has been your biggest challenge with food or nutrition in the past?

Are there specific foods or meals you love and would like included in your plan?

Are there any meals/ingredients you dislike or prefer to avoid?

Is there anything else you'd like me to know before your consultation?

By submitting this form, I acknowledge and agree to the following:

I understand that this program is not intended to diagnose, treat, cure, or prevent any disease. It is designed to provide general nutrition guidance and prepared meals based on the information I have provided.
I acknowledge that any recommendations or meal plans provided are not a substitute for medical advice. I will consult with my physician or healthcare provider before making any significant changes to my diet, especially if I have a medical condition or am taking medications.
I confirm that all information provided in this intake form is accurate and complete to the best of my knowledge.