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Nutrition Consultation Intake

Please complete this intake upon scheduling your appointment. If not received within 12 hours of booked appointment, your appointment will be cancelled.

Birthday
Month
Day
Year
Gender
Female
Male

Anthropometrics

Lifestyle

What would you consider your daily activity level including exercise?
Very light- sitting most of the day
Light- a mix of sitting, standing and light activity (example: teacher)
Moderate- continuous gentle activity (example: restaurant server)
Heavy- strenuous activity throughout the day (example: construction worker)
What would you consider your weekly exercise routine?
No current exercise routine
1-3 hours gentle exercise (walking)
3-4 hours moderate exercise (running, exercise classes, peloton)
4-6 hours moderate/intense exercise (crossfit, weightlifting)
Any special nutrition restrictions?

Health History

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