One-off Nutrition Plan Questionnaire

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JCN Nutrition Consultation

Welcome to your JCN Nutrition plan. Jake Campus Nutrition plans are designed to ensure our clients continuously progress towards their goals and more importantly, are able to achieve longterm results. HOWEVER, our one off plans are designed to help get you started on your journey or if you have been a previous JCN client, to keep you progressing from where you left off. We will be creating you a customised plan to help you achieve your goals through the information you provide in this nutrition consultation, being this pre-assessment form.

Plan progression

Once you receive your plan, you will find notes on the final pages which include tips for progression throughout this one off plan. There is no such thing as a one plan fits all and no plan should or can be followed forever to keep seeing the results you intend to achieve. We recommend that you purchase your next plan within 4-6 weeks to ensure we can make amendments as your body continues and adapts to your current protocols. You will receive a unique code at the 4 week mark which will discount you should you require an updated plan by this time or if you would like to work closely with a nutritionist.

Personal Details

Name(Required)

First Last

Email - please use the one you signed up with(Required)

Enter Email Confirm Email

Age(Required)

Gender(Required)

Height (CM)(Required)

Weight(Required)

Country(Required)

If you don't measure it you cant track it!

Photos showcase a better all-round understanding and starting point for us to design a plan best suited for you. We encourage you to take weekly progress photos during time on your plan so you can assess your visual progress for yourself.

Please upload your FRONT photo(Required)

Max. file size: 100 MB.

Please upload your BACK photo(Required)

Max. file size: 100 MB.

Please upload your SIDE photo(Required)

Max. file size: 100 MB.

Is this your first time working with us?(Required)

If yes, what was the last JCN plan you completed and how long ago?

If you have recently followed a plan or been tracking your food, what was your most recent calories / macro intake? Eg. 1600 calories, 130g Protein, 250g carbohydrates, 45g fat.

Do you currently track your daily steps? If yes, how many on average do you achieve?

If any, what kind of exercise do you perform each week. EG - 4 X weight sessions or F45/Bodyfit classes etc

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?(Required)

Please explain the intolerance or allergy and its affects(Required)

Are you taking any medication or suffer from any illnesses?(Required)

Please explain medication or illness(Required)

JCN Plan Goals & Limitations

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

What is your main focus for this plan?

You can only select ONE option. This will determine your starting journey with us. FATLOSS: We will create a fat loss plan to best kickstart this goal. MUSCLE BUILDING: We will design a plan to best compliment your training and goals. ADAPTING NEW EATING HABITS: We will create a plan based around the changes you'd like to make to your current diet.

What are you hoping to achieve out this plan?(Required)

What are your limitations or barriers to your goals.(Required)

What are you wanting to achieve by adapting your eating habits?

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 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.

Daily & 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.

Do you work full/part time? If so what is your profession?(Required)

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

How many exercise sessions can you fit in per week?(Required)

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

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?(Required)

Foods you dislike?(Required)

Do you use supplements in your diet?(Required)

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?

How often do you eat out or buy your meals weekly?(Required)

Number value only - no text or special characters

How much alcohol do you consume per week?(Required)

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?(Required)

What do you have for a morning snack and what time do you have it?(Required)

Whats a typical lunch and what time do you have it?(Required)

What do you have for a afternoon snack and what time do you have it?(Required)

What is your typical dinner and what time do you usually have it?(Required)

Do you eat anything after dinner? If so what is it?(Required)

Please list any beverages you would like included in your meal plan - EG. coffee with specific milk/sugar etc.(Required)

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:

I agree and understand the terms and conditions stated below(Required)

Please read the following and tick before proceeding to payment. 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. By accepting the terms you agree not to share or sell to anyone else. Questions or concerns are to be emailed to info@jcn.co.nz and NOT shared to any social media platforms. By ticking this box you understand that any slander of Jake Campus Nutrition on Social Media can cause defamation to the company. All JCN online programs are for ages 18+by ticking below you 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 out options.