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Nutrition - Food Coaching

Every food coach member gets personalized attention to create a plan that focuses on the areas most important to you. Fill out this form below and someone will contact you soon.

If you prefer, you can print out this form to fill out and mail it to the following address:
ForeverFit®
195 South Westmonte Drive
Suite 1128
Altamonte Springs, FL 32714

Name:
Address:
City:
State:
Zipcode:
Phone:
Email:
Age:
Current Weight:	lbs.
Height:	ft. in.

1. What is your immediate and long-term health and Wellness Goal?

2. List daily exercise; if no daily exercise, list last time you exercised and what type of exercise you performed.

3. Are you being treated for any medical conditions currently? List.

4. List medications currently taking or have taken in the last 3 months
a.	e.
b.	f.
c.	g.
d.	h.
5. Do you take daily supplements currently? If so list which ones, how often & what dose.
a.	e.
b.	f.
c.	g.
d.	h.
6. Do you consume water daily? How much? And what other liquids do you consume?

7. What time to you rise most often and what time do you go to sleep? Also note if you have normal sleep patterns or problems sleeping.

8. When you like to snack do you choose foods that are sweet or salty or both?

9. Have you noticed fat being stored around your mid-section where it didn’t used to before? If so when did you begin to notice it?

10. On a scale from 1 – 10; How would you rate your stress with 10 being highly stressed? Also note how you deal with the stress i.e. (eat, drink, smoke, cry, anger, sleep etc.)

11. What type of activity do you perform daily (job related i.e. bricklayer, computer etc.)?

12. Have you ever dieted before? List diets you have tried and estimate the year and how long you were dieting.

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