Inhouse Appointment Application Form

JCN Nutrition Consultation Application

Please submit the application form as soon as possible

JCN Application forms are an essential part of our booking process as we'd like to get you booked in with a team member that can best assess your needs. After you have submitted the form, our team will assess your application and either respond with our booking calendar to secure your booking or will touch base if we require more information regarding your nutrition.

Age requirements*

I am 18 years old or over

It is company policy to be over the age of 18 to participate in a JCN program. Please be mindful we are selective about working with anyone under this age, application will be sent to management for review.

Would this be your first time working with us?*

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

Have you previously seen a Nutritionist, if so what is their name or company?

Are you booking an individual appointment or booking for two?*

Who are you booking with and what is their relationship to you? Please ensure they are aware they must also complete an application form.

Personal Details

Date*

Name*

First Last

Gender*

Age

Physical/postal address*

City and postal code*

Country*

Email*

Phone*

Height (CM)*

Write number only

Weight*

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

How did you find out about this program?*

Medication, Illness, Intolerances and Allergies

We need to dive deep into your current health to ensure we know all the factors that contribute to your diet. Please remember in our terms and conditions we do recommend having a medical checkup whether you choose to do so or not is your decision.

Do any of the following apply to you?*

Pregnant
Breastfeeding
None of the following

Please only select one option

Are you allergic or intolerant to any foods?*

Yes
No

Please explain your allergies or intolerance and it's effects:*

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

YES
NO

Please explain in further details your 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:*

Due to the nature of an online program, we may recommend the change program over the results program or refer you to a specialist in this field.

Please describe this in further detail:*

Due to the nature of an online program we may recommend the change programme over result or refer you on to a Specialist in this field.

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.

Goals & Limitations

Your first consultation is all about understanding your relationship with food, recording your current body composition, and starting you on your first JCN meal plan. We'd like to understand what your goals are so we can create with you an achievable approach.

What are you hoping to achieve out of your appointment?*

What are your limitations to changing your lifestyle?*

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 can 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 an aspect you are looking to change and have us encourage?*

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

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

What equipment do you have access to?

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 so we can work with you to create the best plan for you.

Foods you like?*

Foods you dislike?*

Do you use supplements in your diet?

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

Please tell us what products you currently use and when you are using them:*

Do you track macronutrients?*

You are not required to do this on our program, however, if it's something you are currently doing and plan to keep doing, we will use this to 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 each meal • 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 Weekday

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?*

What's a typical lunch, and what time do you have it?*

What do you have for an 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 from 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:

We will now review the application and touch base as soon as we can with some options.

In-house Nutrition application