Nadia Shalwani

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name *

First

Last

Email *

Phone

Current body-weight in pounds *

add body-fat% if you have that info!

Height *

Food Preferences

Please list in details what you love & enjoy to eat. Even if it does not “sound” healthy! All of your fav foods! When you get to the macro portion- select everything you currently eat and would be open to trying!

List your favorite BREAKFAST meals

List your favorite LUNCH & DINNER meals

What types of PROTEIN do you enjoy eating? *

Select ALL that apply

List your favorite CARBS! *

…sweet potatoes, quinoa, brown rice, tortilla…

List your favorite FATS! *

…avocado, olives, cheeses, coconut oil, peanut butter..

List your favorite FRUITS & VEGGIES *

List some of your sweet/salty cravings. *

When do you usually have these cravings? *

Favorite DAIRY foods, or DAIRY ALTERNATIVES. *

..goat cheese, greek yogurt, oat-milk..

Foods or beverages you CANNOT go without!

Favorite foreign dishes

Example: Pakistani/Indian, Mediterranean, Asian, African…

Beverages you enjoy!

Example: Non-alcoholic (coffee, fresh juices, tea, smoothies) & Alcoholic

How many alcoholic drinks do you consume each week? *

Honesty please!

Are you currently taking edibles or smoking marijuana? *

Honesty please!

Are you currently smoking nicotine? *

Honesty please!

List your favorite restaurants

Cafes & Restaurants.

Preferred Grocery Stores *

Select ALL that apply

Add any additional stores you'd like to add?

Links to store website is appreciated!

Appliances you have available *

How many recipes would you like on your plan? *

1 Breakfast, 1 Lunch, 2 Dinners
2 Breakfasts, 2 Lunch, 2 Dinners
2 Breakfasts, 1 lunch, 2 Dinners
1 Breakfast, 2 Lunches, 2 Dinners
1 Breakfast, 1 Lunch, 1 Dinner

For the week

Would you like to try out prepared meal prep for "back-up &/ or traveling" meal options?

Examples; Snap Kitchen, Hello Fresh

List all physical injuries & weaknesses *

Example: Knee pain, lower back pain..etc

List the people you consider your "support system"

Do you have a therapist? Have you ever worked with one? *

What are you most hesitant about? What are you most excited about? *

In the past, what has been some of your health barriers? *

Upload Any Recent Labs/Blood Work

Click or drag files to this area to upload. You can upload up to 5 files.

Upload Photos of any current nutritional supplements and medications you are taking

Click or drag files to this area to upload. You can upload up to 10 files.

Example: Protein powders, vitamins, prescriptions..

If you are traveling anytime soon: list locations (ZIP), dates and the airport.

Any details that can help with building a travel plan!

Are you a member at a gym? If so, which ones? *

Example; Orange Theory, Lifetime Fitness, La Fitness, Apartment Gym..

What is your current physical activity schedule? How active are you in general? *

Example: Strength training 3x week, cycling 2x week, Light walking daily, or sitting in a desk all day. Goals: aim for training 3 times a week.

What triggers your anxiety? How often do you experience anxiety? *

What does "me" time for you look like? What makes you feel calm, and at ease? *

Example; reading a book, talking to family, praying, meditation..

Do you own a HR monitor/ Step Monitor?

Yes, an Apple Watch
Yes, a Fit Bit
Yes, Other
No, but I want one

Example: Apple watch, Fitbit, Amazon

Do you journal?

Current Energy/Macro Intake (IMPORTANT)

Track 3-4 days of your intake. Preferably 2 week days, and 2 weekend days. Use the “save & resume later” button as you track days before submitting.

Food Diary Weekday 1 *

Example: Breakfast: 2 eggs + 1 cup cooked oatmeal + 1 banana, Lunch: brown rice pasta + 4 oz or hand size chicken breast + vegetables, Snacks: Vega protein bar

Food Diary Weekday 2 *

Food Dairy Weekday 3 (optional)

Food Diary Weekend 1 *

Example- Breakfast: skipped, Lunch: Burger & Fries from hopdoddy…

Food Diary Weekend 2 *

Is there anything else you'd like for your me to know?

ANYTHING you think would help with the program design process.

Please list your availability for weekly coaching sessions. Coaching sessions are 60 min in length each week @ the same time/day.