Nutrition Intake Form Fill out the form below to get connected with one of our team members to schedule a time to come in and tour the studio, check out classes, and FREE MONTH! Part 1: Basic InformationContact Information:Name First Last Date Date Format: MM slash DD slash YYYY Gender*MaleFemaleDOB* MM DD YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Current StatsHeight*Weight*lbs.Goal Weight*lbs.Occupation*Average Work Hours/Week:*Who lives with you?* Spouse or partner Roommate(s) Children Pet(s) Other family Check all that applyPart 2: GoalsRank the following goals in order of importance. 1 being most important and 7 being least importantFat Loss*1234567Muscle Gain*1234567Improved Performance*1234567Improved Health*1234567Improved Strength*1234567Sport Specific*1234567Increased Muscle Mass*1234567Other (comment)Do you have a specific timeline for achieving a specific goal? If so, please specify*What type of progress is most important to you? * Rapid progress, not sustainable slower progress more easily maintained Part 3: Lifestyle:Hobbies & Activities (list):*SleepDo you wake in the night?* Yes No How do you feel when you wake up?*If Yes, what time?* : HH MM AM PM What time do you go to bed?* : HH MM AM PM What time do you wake?* : HH MM AM PM How do you feel when you wake up?*Food & DrinkAre you currently dieting or on a meal plan of any kind?* Yes No If yes, please explain:How many meals/day do you typically eat?*How much pure water do you drink per day?*Do you drink caffeinated drinks (coffee, black tea, soda, etc.)?* Yes No If yes, how much per day on average?Do you drink alcoholic beverages?* Yes No If yes, how many drinks per week on average?Movement & Relaxation:How many days per week do you exercise? Indicate type of activity*How much movement do you get while at work?*On a scale of 1-10, what is your stress level?*Part 4: Medical HistorySupplements, Herbs & MedicationsAre you currently taking any medications or supplements (prescription or OTC)?* Yes No If yes, please list all below, including specific product names and dosages/amounts:Medical HistoryAre you currently under a practitioner’s care for a specific issue?* Yes No If so, what treatments are you undergoing?*Please list all injuries, accidents, diagnoses, surgeries, etc. you have had below:*Do you have any known allergies?* Yes No If yes, please list:Part 5: Miscellaneous informationIf there is any other information you have not already provided that you think might be relevant, please provide it below.*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.