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.

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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