Intake Assessment — Rise & Run Offer

Intake Assessment | Coach Britt

This intake form will help us to create your personalized nutrition plan

Personal Information

Name *

Email *

Phone *

By entering your phone number, you are agreeing to receive SMS messages from Peak Optimization Performance. You can reply with STOP at any time to stop receiving SMS messages.

Assessment Details

First Name

Last Name

Phone Number

By entering your phone number, you are agreeing to receive SMS messages from Peak Optimization Performance. You can reply with STOP at any time to stop receiving SMS messages.

Gender

Date of birth

Weight - (measurement)

Height (inches)

Health issues or physical limitations that might limit your ability to follow the plan

Have you been consuming 1200 calories or less in the past 6 months (if so, please let us know for how long)

Are you currently tracking calories and/or macros? If so, please give us your current calorie and macro targets

Please give us a detailed explanation of your current eating habits and what you think you do well and what you think you struggle with the most

What are your non-negotiables? (think of aspects of your life that you prefer not to give up - social events, date nights, family dinners out, etc)

How many alcoholic beverages do you consume on average per week?

Please describe your current training routine? (include all modalities that you partake in)

Apply

I have a food scale

I have weighed out my food portions before

I am currently weighing out my food portions more than 70% of the time

I am willing to weigh out my food portions

I have tracked my food in an app such as MyFitnessPal, Cronometer, etc

I am willing to track my food

What do you do for work? Would you describe it as a relatively sedentary job or a high activity job?

How would you describe your quality and quantity of sleep on average?

Do you currently meal prep or plan any of your meals for the week? Do you enjoy cooking, meal prepping/ planning?