Form Fill Nutritional Plan | It's A Nu Dai Community Lounge

Full Name*

Preferred Name (if different)

Pronouns

Email Address*

Phone Number*

Preferred Method of Contact: (Email, Phone, Video Call, Other)*

How did you hear about our nutritional services?*

What are your main nutrition and wellness goals? (Select all that apply)*

🏃‍♀️ Weight loss or weight management

💪 Muscle gain or toning

🍎 Improve overall health & wellness

🧠 Better mental clarity and focus

🥗 Improve digestion or gut health

🌱 Adopt a plant-based or specialized diet (vegan, vegetarian, etc.)

🍽️ Eating for energy & vitality

🛏️ Improve sleep quality

Other

If other, please specify*

Do you have any specific dietary restrictions or preferences? (e.g., gluten-free, dairy-free, allergies, etc.)*

Do you have any current health conditions or concerns that may impact your diet? (e.g., diabetes, high blood pressure, digestive issues, etc.)*

How would you describe your current eating habits? (e.g., regular meals, grazing, irregular eating patterns, emotional eating, etc.)*

On average, how many meals do you eat per day?*

Do you snack between meals? If so, what types of snacks do you typically have?

Do you have any current food aversions or cravings?*

How often do you eat out or order takeout/food delivery?*

Do you follow any specific diet plan or eating pattern currently? (e.g., intermittent fasting, keto, paleo, etc.)*

How active are you on a daily or weekly basis?*

Sedentary (little to no exercise)

Lightly active (light exercise/sports 1-3 days/week)

Moderately active (moderate exercise/sports 3-5 days/week)

Very active (hard exercise/sports 6-7 days a week)

Extremely active (training for events, physical labor, etc.)

Do you have any food-related goals that you’d like help achieving? (e.g., meal prepping, eating healthier at work, reducing sugar intake, etc.)*

What type of meals do you prefer?*

Quick & easy (30-minute meals or less)

Meal prep-friendly (make ahead meals, batch cooking)

Diverse & adventurous (trying new cuisines and ingredients)

Simple & straightforward (few ingredients, simple recipes)

Other

If other, please specify*

How much time do you typically have to cook meals per day/week?

What are your favorite foods or ingredients?

Are there any foods you dislike or avoid?

How committed are you to following a personalized nutritional plan? (1 = Not ready, 10 = Fully committed)*

What do you feel has held you back from achieving your nutritional or health goals in the past?*

What would a successful nutritional plan look like for you?

Is there anything else you’d like to share about your nutritional needs, goals, or preferences?

Welcome!