This Form cannot be submitted until the missing
fields (labelled below in red) have been filled in
Please reply so this information can be considered in preparing your Plan.
Please note that all fields followed by an asterisk must be filled in.
Country United States Canada ---------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribadi North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Federated States of Micronesia Moldova Monaco Mongolia Montserrat Morocco Montenegro Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S. Georgia and S. Sandwich Isls. Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam US Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Yugoslavia (former) Zaire Zambia Zimbabwe
When is your birthday? (Day/Month/Year)
Type of Plan Purchased*
---Select--- Everday Sports Nutrition Plan
Marathon Training Nutrition Plan
Mary Meyer Life Fitness
Interested in nutrition coaching in pursuit of (check all that apply):*
Name and date of event you are training for (if applicable):
Events or Training Programs you have completed in the last year (if applicable):
What do you do when you are not training for health or performance? (Check all that apply)*
Current or anticipated workout schedule (frequency, length of time, pace/intensity, weights):*
Do you have a training schedule related to your goals?*
Nutrition Coaching Areas of Interest (check all that apply):*
How tall are you? If you haven't measured recently, go measure now!
How much do you weigh in the morning (after voiding)?*
Body Fat Percentage:
How was your body fat tested?*
---Select--- Not tested (yet!)
Omron or handheld equipment
Resting Metabolic Rate (in calories):
How was your Resting Metabolic Rate tested?*
---Select--- Not tested (yet!)
Medgem or handheld device
VO2Max (if tested)*
Resting Pulse Rate (after sleeping, before rising count pusle for 60 seconds)*
Which of the following statements best describes you?*
---Select--- No weight change in the last year and no weight change is planned.
No weight change in the last year, but weight change is desired.
Lost weight in the last year, but no more change is planned.
Lost weight in the last year and more change is desired.
Gained weight in the last year, but no change is planned.
Gained weight in the last year and change is desired.
If you lost weight in the last year, how much did you lose?*
Which method(s) did you use to lose weight? (Check all that apply)*
If you gained weight in the last year, how much did you gain?*
To what do you attribute your weight gain?*
Have you ever been treated for an eating disorder?*
Are you currently in treatment for an eating disorder?*
How many times a day do you eat or drink something?*
Check any of these statements that describe you:*
List any prescription medications you take on a regular basis.*
List any over the counter medications you take on a regular basis.*
List any nutritional supplements (powders, pills, potions) you take on a regular basis. If known, provide the brand and how much you take daily.*
List any herbal supplements you take on a regular basis.*
Check all current medical conditions (to be considered in your personalized nutrition plan):*
List any food allergies (if applicable):
List any foods/beverages that you will not eat/drink:*
Type any additional information that you think your nutrition coach would like to know about your food, fitness, or lifestyle. If you have a concern that you want to be considered in your Plan, this is a great time to fill in the gaps of the questionnaire!
Please enter the word that you see below.