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KCPT • ONLINE
with Kate Collins
KCPT • ONLINE
with Kate Collins
Progress
2 / 30 · 7%
Public form
Nutrition Coaching Application Form
Progress
2 / 30 · 7%
§ 01
Full name
· Required
§ 02
Email Address
· Required
§ 03
Mobile Number
· Required
§ 04
Age
· Required
§ 05
Gender
· Required
Select an option
Male
Female
§ 06
Height
· Required
§ 07
Current Weight
· Required
§ 08
Goal Weight
· Required
§ 09
Primary Goal:
· Required
Fat loss
Build muscle/gain weight
Better relationship with food
Body recomposition
Improve overall health
Learn how to track calories and macronutrients
Not sure yet
§ 10
What's your biggest motivation right now?
· Required
§ 11
Have you tried to reach this goal before?
· Required
Yes
No
§ 12
Daily activity level?
· Required
Select an option
Mostly sedentary (desk job, little movement)
Lightly active (some walking, on feet at times)
Moderately active (active job or regular exercise)
Very active (physical job and training)
Athlete (training 5 times + per week)
§ 13
Do you currently exercise?
· Required
Select an option
Yes, consistently
On and off
Just starting out
Not currently
§ 14
Current stress levels (1= not stressed - 10= extremely stressed)
1
2
3
4
5
6
7
8
9
10
Low
High
§ 15
How would you rate your sleep?
· Required
Select an option
7–9+ hours, feeling rested
6–7 hours, okay
Less than six hours
Poor quality sleep
§ 16
Have you tracked calories & macros before?
· Required
Select an option
Yes, I track consistently now
Tracked before but stopped
I've tried a few times
I've never tracked before
§ 17
Do you use MyFitnessPal?
· Required
Select an option
Yes, I use it regularly
I have it, but don't use it
No, I haven't used it
I use a different app
§ 18
Do you have any food allergies or intolerances?
· Required
No
Gluten/wheat
Nuts
Seafood/fish
Dairy/lactose
Eggs
Soy
Other
§ 19
Dietary preference for eating style
· Required
No restrictions, I eat everything
Vegan
Vegetarian
Pescartarian
Halal
Carnivore/keto
Other/flexible
§ 20
Do you drink alcohol?
· Required
Select an option
No
Occasionally (1-2x month)
Socially on weekends
A few nights per week
§ 21
Any medical conditions or injuries I should know about?
· Required
Yes
No
§ 22
If YES, Explain
§ 23
What does your social eating life look like? (takeaway- how many times per week?)
§ 24
Share a day of eating- (add as much infomation as you can- times of meals, quantities etc)
· Required
§ 25
How committed are you to making a change right now? (1=not at all - 10= extremely committed)
· Required
1
2
3
4
5
6
7
8
9
10
Low
High
§ 26
Do you have any concerns following a nutritional plan or calories/macronutrients?
· Required
Yes
No
§ 27
If YES, explain:
§ 28
Is there anything else you want to share?
§ 29
Today's date
· Required
Pick a date
§ 30
All of the above is truthful/ accurate
· Required
Click to Sign
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KCPT • ONLINE
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