Full Name*

Email*

Phone Number

Age

Height

Current Weight

Goal Weight

Primary Goal
Fat LossMuscle GainBody RecompositionHormone SupportEnergy ImprovementOther

Why is this goal important to you right now?

What has prevented you from reaching this goal before?

Medical Conditions

Prescription Medications (include dosage)

Supplements Currently Taking

Current Cycle Status
Regular cyclesIrregular cyclesPeri-menopausalMenopausalPost-menopausalHysterectomy

If peri/menopausal, what symptoms are you experiencing?
Night sweatsHot flashesSleep disruptionWeight gain (midsection)Mood changesLow libidoBrain fogFatigueAnxietyNo symptoms

Any additional hormone-related concerns?

Breakfast (be specific)

Lunch

Dinner

Snacks / Junk Foods

Weekend Eating Differences

Average Hours of Sleep

Stress Level (1–10)

Are you willing to track your food?
YesNo

Preferred Accountability Method
TextEmailAppWeekly Call

I understand this nutrition guidance is for educational purposes only and I release Highly Favored Fitness, LLC and Coach JBJ from liability.