Food Intake and Activity

Please take the time to fill out this form on what a typical day is like for you. This is crucial information for us to best assist you with creating the most effective nutrition and exercise program specifically for YOU.

Please list everything as fully and in as much detail as possible.

Date*
MM slash DD slash YYYY
First Name:*
Last Name:*
Email:

A copy of this form will be sent to this email address.
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
Time:

: Hours

Minutes

AM/PM
Food Intake:
BED TIME: Do you fall asleep easily?
- Yes
- No
- Sometimes
BED TIME: Do you sleep through the entire night?
- Yes
- No
- Sometimes
MON. - Please list or describe typical exercise or activity for the day:
TUE. - Please list or describe typical exercise or activity for the day:
WED. - Please list or describe typical exercise or activity for the day:
THU. - Please list or describe typical exercise or activity for the day:
FRI. - Please list or describe typical exercise or activity for the day:
SAT. - Please list or describe typical exercise or activity for the day:
SUN. - Please list or describe typical exercise or activity for the day:
SUPPLEMENTATION & FLUID INTAKE - Please list or describe typical daily intake of nutritional supplements and fluid intake (water, sports drinks, coffee, tea, etc.).
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