Guided Fertility

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Nutrition Intake Form

Your information will be confidential and will only be shared with Jessica.

First Name

Last Name

Health Background

Please List Health Conditions

Current Medications and Supplements

Dietary Needs & Preferences

Do you have food allergies, intolerances,or restrictions?

Foods you Dislike or Avoid

Foods you Enjoy

Diet Diary

Typical Breakfast

Typical Dinner

Typical Lunch

Typical Snacks

Hydration Status

Daily Water Intake (oz or cup)

Daily Caffeine Intake (cups)

Alcohol Per Week

Time, Budget & Meal Prep Capacity

Weekly Grocery Budget

Grocery Stores You Use

Do you Meal Prep?

If yes, how often?

Which meals do you realistically have time to prepare during the week?

Breakfast

Lunch

Dinner

Meal Approach that Feels Most Sustainable

Structured Meals

Quick Recipes

Batch Cooking

Simple Meals

Grab-and-Go

Digestion & Body Signals

Symptoms You Experience

Bloating

Gas

Constipation

Diarrhea

Heartburn

Nausea

Cravings

Blood Sugar Crashes

Are Bowel Movements Regular?

Do symptoms change at different points in your cycle?

Lifestyle Context

Current Stress Level

Average Hours of Sleep Per Night

Smoking Status

Movement or Exercise Routine (Type and Frequency)

Do You Use Recreational Drugs?

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