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Caileen Thomas
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Key Nutrition
2022-02-14T12:46:06-06:00
Caileen Thomas
Nutrition Coach
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Online Checkin Form
Client Information
First Name
Last Name
Body Composition
What was your weight this morning?
Measurements
Arm
Chest
Thigh
Waist
Meals and Intake
On a scale of 1-10 rate your adherence to nutrition/macros?
—Please choose an option—
1
2
3
4
5
6
7
8
9
10
Water Intake - How many ounces daily on average?
What describes your hunger best?
—Please choose an option—
Extremely Hungry
Moderately Hungry
Just Right
Too Full
How many unplanned meals did you have? i.e: Planned on Chicken and Veggies, but ate Subway instead.
For example: you planned to have chicken, rice and a veggie BUT had a burger instead.
How many times did you eat out this week?
Do you have any foods that you are craving or would like added to your meal plan?
No
Yes
Tell us about the foods. We will see if they will fit in the macros!
Activity, Mood, Sleep
How is your energy?
—Please choose an option—
Really Good
Above Average
Average
Below Average
Poor
Rate your energy from 1-5
—Please choose an option—
1
2
3
4
5
Any changes in your mood or attitude? i.e: Irritable, Cranky, Happier, More Anxiety
No
Yes
Please explain the changes
Workouts - How many times?
Are you recovering from them efficiently? For example: excessive soreness, energy after, pain, etc.
No
Yes
Sleep - Average hours per night
Stress - Rate from 1 to 10 (1 being no stress)
1
2
3
4
5
6
7
8
9
10
Do you have any new life stressors?
No
Yes
Describe the new stressors
Additional Information
Did you have any wins this week?
No
Yes
Tell us about your wins.
Did you have any struggles, if so please explain:
Do you have any additional bio feedback or input that will assist us in putting together your plan?
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