Your Name (required)
Your Email (required)
Name of BLOC Strength Coach
Date of Birth
Indicate feet/inches or cm
Indicate lbs or kgs
Body fat percentage
Indicate method used
At nipple line. Please indicate inches or cm
At navel. Please indicate inches or cm
At widest part. Please indicate inches or cm
Please provide City & State / City & Country
Please describe your primary short- and long-term goals in regards to training, body weight/body composition, and performance.
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.
Do you currently track your macros using a macro-tracking app (like MyFitnessPal?)
Current protein/carbohydrate/fat intake (in grams) and calories (if ballpark figure please indicate).
Are you currently following a controlled diet? If so, please specify.
Please list any medications you take.
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?
Approximately how many times have you attempted to lose weight?
Do you own a food scale?
Do you own a weight scale?
Do you own a measuring tape?
What foods do you prefer? Please include likes, dislikes, cultural foods, etc.
Please list any food and/or drug/supplement allergies.
Please list all current supplements and/or vitamins you are currently taking if applicable.
Approximately, how many hours of sleep do you get per day?
Please include any other pertinent information, concerns, or questions you have and we'll get to work!