Your Name (required)
Your Email (required)
Name of BLOC Strength Coach
MaleFemale
Age In years Date of Birth mm/dd/yyyy Height Indicate feet/inches or cm Weight Indicate lbs or kgs Body fat percentage Indicate method used Chest Measurement At nipple line. Please indicate inches or cm Waist Measurement At navel. Please indicate inches or cm Hip Measurement At widest part. Please indicate inches or cm Location Please provide City & State / City & Country Goals Please describe your primary short- and long-term goals in regards to training, body weight/body composition, and performance. Eating Habits What does a typical day of eating look like for you on training days and non-training days? Is your eating impacted by your work schedule and/or environment? If so, please elaborate. What does a typical day of eating look like for you on training days and non-training days? Is your eating impacted by your work schedule and/or environment? If so, please elaborate. Tracking Do you currently track your macros using a macro-tracking app (like MyFitnessPal?) YesNo Nutrition Intake Current protein/carbohydrate/fat intake (in grams) and calories (if ballpark figure please indicate).
Controlled diet Are you currently following a controlled diet? If so, please specify.
Medications Please list any medications you take.
Medical Conditions Please check any and all conditions that apply to you personally so that we can best pair you with your Nutrition Coach: Type I DiabetesType II DiabetesHeart DiseaseHypothyroidismHyperthyroidismChronic Kidney DiseaseCancerHIV/AIDsIrritable Bowel SyndromeCrohn’s DiseaseUlcerative ColitisHistory of GI surgery (for example, gastric bypass)Rhematoid ArthritisGERDNone
Any other conditions not mentioned above that your Nutrition Coach should be aware of?
Weight Loss Approximately how many times have you attempted to lose weight?
Food Scale Do you own a food scale? YesNo
Weight Scale Do you own a weight scale? YesNo
Measuring tape Do you own a measuring tape? YesNo
Food preferences What foods do you prefer? Please include likes, dislikes, cultural foods, etc.
Allergies Please list any food and/or drug/supplement allergies.
Vitamins/supplements Please list all current supplements and/or vitamins you are currently taking if applicable.
Sleep Approximately, how many hours of sleep do you get per day?
Other Notes Please include any other pertinent information, concerns, or questions you have and we'll get to work!