Nutrition Coaching Application

First Name

Last Name

Phone

Address

Birthday

Instagram Handle

Facebook Page URL

Weight (lbs)

Height (in)

How did you hear about RevelationRx Nutrition

Tell us more about yourself!

History with food insecurity

Do you wear any fitness trackers- Apple Watch, Fitbit, Garmin, Whoop, Oura?

Have you ever tracked your macros before?

Do you track your food intake with MyFitnessPal or a similar app?

If you use an app to track your food intake, which app, and what is your username?

Do you have access to a food scale?

Current Eating Pattern - What do you typically eat in a day?

Breakfast:

Lunch:

Dinner:

Approximately how much water do you drink daily?

Do you smoke or drink? If so, how much and how often?

Please list all current medications, supplements, or PEDs you are currently taking

What does your current training routine consist of?

How much cardio do you perform on a weekly basis? Please include total time and type.

Please tell us about your short and long term health goals.

Have you had any recent bloodwork drawn? If yes, on what date? Do you know your TSH, T3, T4, HDL, LDL, Total Cholesterol, Vitamin D? Any other labs that were out of normal range?

Do you have any injuries, medical conditions, or food allergies that we should know about?

Are you willing to track your food intake or are you looking for lifestyle changes and not changes?

Any history of an eating disorder or disordered eating?

Tell us what you would like to get out of this dietary consultation!

Do you know your Enneagram Number? If so, what is it?