Ambassador - Online Nutrition - Jake Campus Nutrition

JCN Online Nutrition Consultation

You are about to begin your Jake Campus Nutrition online consultation and sign up process.

We are diving in to understand your current diet, exercise, and most importantly GOALS. You will be required to set up your payments before submitting your details. Please ensure you have read the terms and conditions of the program before submission.

Personal Details

Date*

Age requirements*

I am 18 or over

It is company policy to be over the age of 18 to participate on our online program.

Age

Gender*

Do any of the following apply to you?*

Pregnant
Breast feeding
None of the following

Please only select one option

How long have you been breastfeeding for?*

We will be encouraging a Lifestyle change approach and as company policy will not work on fat-loss through pregnancy.

Name*

First Last

Email - please use the one you signed up with*

Enter Email Confirm Email

Photos showcase a better all-round starting point and further down the track your results – our bodies can transform in many different ways – not just weight.

Please upload your front photo for us*

Please upload your back photo for us*

Height*

Write number only in Cm

Weight*

Address*

City and postal code*

Country*

Phone*

Is this your first time working with us?*

What Jake Campus programme were you on and how long ago?*

Are you doing this programme with anyone else in your house hold?*

Is your partner or flatmate on this journey with you and also following a plan? If so let us know we can work plans in together to make prep in the house hold easier.

What is their name?*

We would greatly appreciate you letting us know how you found out about our services:

How did you find out about this program?*

What is the name of your gym or trainer who recommended our services?*

Can you please share with us how you heard about our program?*

Medication, Illness, Intolerances & Allergies

We need to dive deep into your current health so we can know all the factors that contribute to your diet. Remember I the terms and conditions we do recommend having a medical checkup. Whether you choose to do so or not is your decision.

Are you allergic or intolerant to any foods?*

Yes
No

Please explain the intolerance or allergy and its affects*

Are you taking any medication or suffer from any illnesses?*

YES
NO

Please explain medication or illness*

Have you ever experienced or currently have an eating disorder?*

Yes
In the past I have
No

Please only select one option

Please describe this in further detail:*

We'd like to start you on the JCN change program! Due to the nature of the online program, we recommend the change approach over the result. Your safety is the most important thing to us and to ensure we continue to nurture a healthy relationship with food we believe this is the best focus to start with. Please be mindful any concerns for your safety may occur in us recommending a specialist.

JCN Plan Goals & Limitations

Lets start by understanding the approach you'd like to take to get started then set some goals.

How would you like to kickstart your plan?*

You can only select ONE option. This will determine your starting journey with us. **Lifestyle Results**: Focuses on your goal and has a stricter initial program to focus on the results you want but leads into a maintenance approach to maintain your results longterm. **Lifestyle Change**: Discover a healthy balance with the JCN team. Includes; eating out advice and options as well as recipes. Please bare in mind whilst the change plan may result in weight loss this is not the focus. If your core focus is weightloss we encourage starting with a result approach.

What are you hoping to achieve out of your JCN Lifestyle Plan?*

What are your limitations to changing your lifestyle?*

What are you wanting to achieve longterm out of the Lifestyle Change Programme?

Better choices when eating out
New recipes - getting more creative with healthy meals
Controlling appetite
How to eat better as a family
Create sustainable habits
Consistent eating patterns

What are you wanting to achieve in the short term of your program?*

Whats your SMART goal?

A smart goal includes all points below. Whilst we are working for a result we also want to create LONGTERM results. So we must be realistic. S:pecific M:easurable A:chievable R:ealistic T:imely You may have to make some short term sacrifices in order to reach you goal but we must keep in mind the long game.

What other types of diets have you done in the past 5 years? Was the diet successful?

Example; Keto, Low carb, Weight Watchers, Paleo, Shake Meal replacements.

Do you work full/part time? If so what is your profession?*

Physical Activity

We need to understand what type of physical activity you are currently doing or able to get into your day to help us build a plan to achieve your goal.

What type of physical activity do you enjoy and how often does this fit into your weekly routine?*

We can support your fitness, is this a aspect you are looking to change and have us encourage?*

Great! We will work with you by giving advice and if desired some workout guidelines. Is there any extra details you'd like us to know around your fitness?

Explain your exercise regime; Frequency, time of day, duration and type of exercise you do and enjoy:*

Would you like us to guide your exercise regime to compliment you goal?*

How many exercise sessions can you fit in per week?*

What equipment do you have access too?

Gym membership
Home equipment - Weights
Home equipment - Cardio
Outdoors

Lifestyle Food & Habits

Be honest and let us know everything! Foods you like, dislike, current habits and anything else we should know. The more information the better we can work with to create the best plan for you.

Foods you like?*

Foods you dislike?*

Do you use supplements in your diet?

In our programme some supplements can be great for your diet, is this something you are open too?*

Please tell us what products and when you are using them. If you are not using a protein supplement are you open to introducing one?*

Do you track macronutrients?*

You are not required to do this on our program, however if its something you are currently doing and plan to keep doing we will use this tailor our approach to fit!

How often do you eat out or buy your meals weekly?*

How much alcohol do you consume per week?*

Food Log

To assist you in reaching your goals and to customise the best nutrition plan for you, it is important to know your current eating habits. On the following page please write down everything you eat and drink including the time and quantities. Do not try to change your eating habits during the Three Day Food Log. Helpful Hints • Record what you have eaten as soon as possible after meals. • Preparation: How was the food cooked? Was it baked, grilled, fried or steamed? Was it fresh, frozen or canned? • Portion Size: Indicate how much of each food you eat by using cups, grams, teaspoons, or tablespoons, or a “handful.” • Include the fluids that you drink: List the amounts, types and times that you drink them. • Include the “extras” or condiments you eat: Do you put milk or sugar in coffee or tea? Do you use tomato sauce, mustard or mayonnaise etc. on your meals? • Workouts: Record the time and short explanation of your workouts. • Notes: Make note of how you are feeling throughout the day (e.g. are you hungry, low in energy etc.)

Average Week day

What is your go to Breakfast and what time do you have Breakfast?*

What do you have for a morning snack and what time do you have it?*

Whats a typical lunch and what time do you have it?*

What do you have for a afternoon snack and what time do you have it?*

What is your typical dinner and what time do you usually have it?*

Do you eat anything after dinner? If so what is it?*

Average Weekend diet

Weekends can tend to differ to our weekly diet as we may be out and about, away from home, indulge in eating out or your diet may be the same as your weekday.

Please explain your weekend diet and eating times for us:

Please read carefully before submitting application.

I have signed and agree to the JCN ambassador contract issued.*

I agree and understand the terms and conditions stated below*

We recommend all clients have a medical checkup prior to starting their nutrition program By accepting the terms and conditions below you understand it is your responsibility whether or not you choose to have this checkup and that any health issues or mental illnesses prior or throughout your program must be shared with Jake Campus Nutrition. You understand that the team at Jake Campus Nutrition are not medical physicians, they consult and recommend nutrition services only. If you have any future queries or concerns regarding your meal plans or health you will inform the team at Jake Campus Nutrition immediately. For medical advice you know to seek your doctor for further assessment and share these results with your nutritionist. Your Jake Campus Nutrition plan has been customised to you and your lifestyle.

All JCN online programs are for ages 18+by ticking below you give consent you are 18 or over. If you seek nutritional advice and you are under the age of 18 you must contact our customer support team to discuss our options.

Lastly we need your commitment!

Im committed to my SMART goal. I will look to put in place actionable steps to achieving my goal. I commit to open communication with the Jake Campus Nutrition team. I will let them know about my successes and also my obstacles. I understand I am working towards a longterm result.