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Group Training

Nutrition Intake Form

Birthday
Month
Day
Year
Can this # be texted?
Yes
No
Have you worked with a nutritionist before?
Yes
No

Family History (check all that apply):

Family History

Allergies: (List all food allergies)

Activity Level:

Exercise:

Exercise:

At work, I am:

At work I am:

Food Frequency:

I eat breakfast:

I eat breakfast:

On average I eat out on how many days:

On average I eat out on how many days:
0
1
2
3
4
5
6
7

Servings per day of each of the following:

Vegetables (not including potatoes and corn):
0
1-2
3-5
5 or more
Fruit (fresh, frozen, or canned)
0
1-2
3-5
5 or more
Processed meat (bacon, sausage, deli, etc.):
0
1-2
3 or more
Sweetened beverages (soda, iced tea, etc.):
0
1-2
3 or more
Water
0 glasses
1-3 glasses
4 or more glasses

I feel my overall diet is:

I feel my overall diet is:
Poor
Fair
Good
Very Good

Barriers to Healthy Living

Choose "agree" if the following statements are barriers that apply to you, "disagree" if they are not)

I don't have time to prepare healthy foods
Agree
Disagree
I can't afford healthy food
Agree
Disagree
I don't know how to prepare heathy food
Agree
Disagree
I have trouble making healthy foods my family will eat
Agree
Disagree
Not Applicable
My co-workers eat out/bring in "unhealthy" foods
Agree
Disagree
Not Applicable
Healthy food does not taste good
Agree
Disagree
I often have powerful cravings for "unhealthy" foods
Agree
Disagree
I don't know what healthy food choices are
Agree
Disagree
My significant other will not change his/her eating habits
Agree
Disagree
Not Applicable
I eat when I feel sad/depressed/stressed/happy/other emotion
Agree
Disagree
I feel guilty when I eat something "bad"
Agree
Disagree
I get mad at myself for not making healthier choices or having more "willpower"
Agree
Disagree
I often eat past the point of felling "full"
Agree
Disagree
I don't have time to exercise
Agree
Disagree
I think exercise is boring
Agree
Disagree
I don't have a place or equipment to exercise
Agree
Disagree
I don't know what to do when I exercise
Agree
Disagree
I feel self-conscious when I exercise
Agree
Disagree
I'm worried I will get hurt when I exercise
Agree
Disagree
I do not feel worthy of weight loss/improved health
Agree
Disagree
I feel ready to make lifestyle changes (0 = not ready; 5 = very ready)
0
1
2
3
4
5

Personal Health and Fitness Goals:

Nutrition Coaching Disclaimer

The information provided by Major Sports Performance through nutrition coaching services, resources, and related communications is intended for general informational and educational purposes only. It is not intended as, nor should it be considered a substitute for, professional medical advice, diagnosis, or treatment.


Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition, dietary changes, or before starting any new health, nutrition, or exercise program. Never disregard professional medical advice or delay seeking it because of information you have received through our services.


By participating in nutrition coaching with Major Sports Performance, you acknowledge that you do so voluntarily and at your own risk. Major Sports Performance does not guarantee specific results and shall not be held responsible for any adverse effects, consequences, or health issues that may arise from your participation in our programs or reliance on our advice.


Individual results may vary, and the effectiveness of any nutrition or wellness strategy will depend on personal commitment, underlying health conditions, and other factors outside of our control.


If you have or suspect you may have a medical condition, consult your healthcare provider before engaging with our services.

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Wheaton, Il 60137

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