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Nutrition Intake Form

BASIC INFO

City
State/Province
Zip/Postal
Country

NUTRITIONAL PROGRAMS

Results from training sessions are only as good as the nutrition used in support. Appropriate nutritional recommendations are often the lynchpin on which fitness success rests. Unfortunately, it is also the most difficult area in which to gain compliance. To that end, we have developed this program using 4 simple steps to deliver profound results. This 4-step process ensures the programs designed are customized to you, your life, and your commitment level.

  • Step 1: Identify Your Goal
  • Step 2: Determine Your Goal
  • Step 3: Getting the Right Programs for You
  • Step 4: Putting in the Effort and Tracking Progress

STEP 1: IDENTIFY YOUR GOAL

If we don't know where we are trying to go how will we know how to get there? The answer is "we won't." This is why every successful program must begin with understanding the goal. Goals may include:

  • BODY COMPOSITION GOAL: Which may include a desired body fat percentage, muscle mass increase, achievement of the desired dress size, goal weight, etc.
  • HEALTH GOAL: Such as lowering cholesterol, lowering blood pressure, reducing anxiety, improving energy levels, regulating digestion, sleeping through the night, etc.
  • PERFORMANCE GOAL: This could be setting a PR in a race, improving speed, vertical jump, endurance, 1 rep max, ability to recover, for a sport, etc.

Before we go any further, take a moment to list your short-term (1 month), medium term (3-6 month), and long-term (6+ months) goals.

STEP 2: DETERMINE YOUR SUCCESS BLOCKING FACTORS

Before you embark on this journey, it is important for you to understand how willing you are to make changes to your nutritional habits. The results of this form will help us understand how to proceed with your training and nutritional programming. We must determine potential success blocking factors including hormonal imbalance, readiness to change, your current kitchen environment, constitutional factors, and toxicity symptoms to determine the next best steps towards your goal.

DIET

LIFESTYLE

MEDICATIONS

1 = Not • 10 = Extremely
1 = None • 10 = Plenty
1 = None • 10 = Plenty
1 = Cold • 10 = Hot

GROUP 1

GROUP 2

GROUP 3

GROUP 4

GROUP 5

DIGESTION

EMOTIONS

EARS

ENERGY

HEAD

EYES

JOINTS & MUSCLES

SINUS & NOSE

LUNGS

MIND

WEIGHT

MOUTH & THROAT

SKIN

OTHER

STEPS 3 & 4: GETTING THE RIGHT PROGRAM AND COMPLETING TASKS / TRACKING PROGRESS

Step 3 is getting the right training and nutritional programs custom designed by Dusten and his team based on the information you're providing in this form. Then, Step 4 is simply you putting in the effort, following the programs to the letter, and tracking your progress (which we will be doing with you to ensure success). Together we will hit your goals and see your results.
It's that easy!