Landing Test |Prime Meals

Email * example@example.com

Phone Number * Please enter a valid phone number.

Address * Street Address

Street Address Line 2

City

State / Province

Preferred Contacts *
Phone Call Text Message Other Email

Whats the BEST days and times are you available for 20 mins health coaching sessions?

Birth Date

Month

Day

Year

Age *

Ex: 23

What are your health goals? *

Do have a primary care doctor/ practitioner provider? *

When was your last annual health physical with lab work (was hormone panel included)? *

Do you have any of the following? *

Blood Presssure
Diabetes - Type 2
obesity BMI > 30
Other

Diabetes - Type 1
Gout
High Lipids Levels

Are you taking any medications for *

Diabetes
High blood pressure
Hight Cholesterol
Other

Thyroid
Lithium
Coumadin (Warfarin)

Please list ALL supplements you are currently taking? (Apply N/A for none) *

Are you pregnant? *

Yes

N/A

Are you nursing? *

Yes

Please describe how often you’re nursing? *

Height * Height in inches

Weight * Weight in lbs

What is your current Body Fat Percentage % number? *

What is your Goal Body Fat Percentage % number? *

What is your current lean body mass weight? *

What is your Goal lean body mass weight? *

What is your current BMI number? *

What is the BMI value for the weight you want to maintain at? *

Have you tried to lose weight before? *

Yes

Have you tried to lose weight before? *

In general, what time do you go to bed? *

In general, when do you wake up? *

Do you wake up feeling rested? *

Yes

Other

How is the quality of your sleep? *

How many hours do you sleep? *

Less than 5 hours

7-8 hours

More than 10 hours

5-6 hours

9-10 hours

In a day, how much water do you drink usually? *

In a day, how much coffee do you drink usually? *

In a week, how much alcohol do you consume usually? *

What are your fitness goals *

Burn fat/build tone muscles

Strength and conditioning

Health and Life Style

Stress managment

Build self confidence/esteem

Other

What are your overall fitness and exercise goals? *

Do you smoke? *

1 Pack/day

+3 Pack/day

Less than one pack

Do you do any exercise? *

1-3 a week

Everyday

3-5 a week

Never

Do you prefer to train? *

Home

Gym

Both

How many days a week are you available to weight train and do cardio exercises? (List days and times) *

What kind of exercise do you participate in? *

Are there things you would like to do that you are currently unable to? *

What you do for work? *

Do you enjoy what you do for work? *

Are there any other stress in your life (explain most stressful aspect of your life)? *

Lowest

Highest

Select what you do to relief stress? *

Pray

Meditation

Massages

Nothing

Execise

Yoga/Pilates

Other

When do you eat your first meal? *

When do you eat your last meal? *

Do you know how to calculate and track your macronutrients for your health and fitness goals? *

Yes

Do you know how to use flexible dieting to reach your fitness and health goals? *

Yes

Do you have any food allergies? *

Yes

Whats is your blood type? *

Do you currently FAST? If yes, how many times a week? For how long? *

Are you interested in learning about fasting lifestyle for health and spiritual benefits? *

Yes

Undecided

How many meals per day do you eat? *

What FOODS YOU DISLIKE? *

What are your FOODS PREFERENCE meals you like to eat per day? *

Please explain what you usually eat for breakfast? *

Please explain what you usually eat for Lunch? *

Please explain what you usually eat for Dinner? *

Do you snack? If yes, what do you snack on? *

Please write down everything you eat and drink for one full day (from the time you wake up until the time you go to sleep) Be as accurate as possible when recording amounts (Breakfast/Lunch/Dinner and Snacks). *

How’s your digestion with foods? *

I don't feel bloated or gassy and have 1-2 bowel movements a day

I feel bloated/gassy and have 1-3 bowel movements a day

Other

Usually I feel bloated/gassy & have infrequent bowel movements

Never I don't feel bloated/gassy & have infrequent bowel movements

Have you ever completed a 21 day detox nutrition plan (Yes or No)? If Yes, When was the last time you completed the detox nutrition plan? How did you feel? *

How often do you eat out in a week? *

Always

Sometimes

Never

Usually

Rarely

Other

Where do you typically eat out? *

Where do you typically Grocery Shop? *

Test

HEALTH & FITNESS INTAKE FORM

Medical

Measurements

Sleep

Hydration

Weight Training/ Cardio

Stress

Nutrition