Coaching / Intake form

Coaching programme

Your starting point, with me.

Everything we need to understand your body, your skin, your routine and your goals, so your plan is built around you, not a template. Answer honestly; nothing here is judged. It goes step by step, and you can choose to save your answers on this device to finish over a few days.

00

Your first 7 days

01

Complete this intake

Profile, medical history, skin, gut, cycle, hormones, hair, lifestyle and how you feel today.

02

Take your measurements

Morning, soft tape, relaxed breathing. Guide in section 13.

03

Share your blood tests

Your most recent results with dates, interpreted by your doctor. Checklist in section 14.

04

Journal your food for 7 days

In MyFitnessPal, eating exactly as you normally do. Section 15.

05

Wear a Whoop band

24/7 for the same 7 days to capture sleep, stress, strain and recovery. Section 16.

06

Send it all

This form goes step by step and sends itself from the last step. Photos or PDFs of tests and exports go by email. Then we build your plan together.

Important. This programme supports your nutrition and lifestyle. It does not diagnose or treat disease and does not replace your doctor or dermatologist. Never stop or change prescribed medication on your own. Everything you share stays between us and is used only to build and adjust your plan. Progress photos are for you; I don’t need to see them unless you want me to.

Step 1 of 11About you
01

About you

Sex
Where do you work?
Emergency contact
How ready do you feel to make changes?
How confident are you that you can stay consistent?
02

Medical history

Please include everything, even if it feels unrelated. Many conditions are linked to skin, gut and hormones.

Diagnosed conditions
Current medications
Hormonal contraception?
Current supplements
Surgeries and hospital stays
03

Skin, inflammation and immunity

Skin reflects what happens inside: stress, sleep, gut, hormones and blood sugar. Include anything from the past too.

Skin issues, now or in the past
Current or past?
Diagnosed by a doctor?
Inflammatory and autoimmune conditions
If you have a skin condition, where is it right now?
Better, the same or worse than 6 months ago?
Severity
Itch
Pain or cracking
Confidence
Dryness
Redness
How often does it flare?
Joint pain, swelling or morning stiffness
Puffiness or swelling (face, hands, ankles)
Frequent colds, infections or slow healing

Joint pain or swelling should always be checked by your doctor. Keep any prescribed treatment.

What triggers flare-ups?
Treatments, current and past
04

Digestion and gut

Your gut and skin are closely connected. Please describe a typical week right now.

Do you have a bowel movement every day?
Usual stool type
Do you feel fully emptied afterwards?
Bloating
Gas
Stomach burning or heartburn
Acid reflux or sour taste
Constipation
Diarrhoea or urgency
Stomach pain or cramps
Nausea
Feeling heavy or too full after meals
Mucus or blood in stool
05

Your cycle and hormones

Your cycle is one of the clearest signals of how your body is coping. If you track it in an app, screenshots are welcome by email. Skip this section if it does not apply to you.

Is your cycle regular?
Flow
Clots, or changing protection every 1 to 2 hours?
Spotting between periods?
Pregnant, breastfeeding or trying to conceive?
Period pain (1 = none, 10 = cannot function)
PMS intensity
Before or during your period you notice
Always feeling cold, or cold hands and feet
Hair thinning or shedding
Dry skin or brittle nails
Unwanted facial or body hair
Swelling or puffiness (face, fingers, ankles)
Low libido
Hot flushes or night sweats
06

Hormones and metabolism

Hormones, thyroid and blood sugar shape energy, weight, skin, hair, mood and your cycle. Tick anything diagnosed or suspected, even if it was years ago.

Hormonal and reproductive
Thyroid and adrenal
Blood sugar and metabolism
About your diagnosis
Strong sugar or carb cravings
Energy crash or sleepiness after meals
Shaky, irritable or dizzy when hungry
Weight gain mainly around the belly
Acne on jaw, chin or back
Weight hard to lose despite effort
Feeling cold, slow or puffy
Racing heart or heat intolerance
Dark velvety patches (neck, armpits)
Skin tags
07

Hair and reproductive health

Hair often changes 2 to 6 months after a trigger, so think back a little. Share only what you are comfortable with.

Are you noticing hair loss or thinning?
Hair shedding when washing or brushing
Since when?
Where do you notice it?
Anything that happened 2 to 6 months before it started?
Grey hair
Started going grey before 30?
Greying faster than before, or than your family?
Breastfeeding now?
Trying to conceive now?
Difficulty getting pregnant (over 12 months)?
Pregnancy complications (diabetes, blood pressure)?
08

How you feel today

Score each one from 0 to 10, thinking about the last two weeks. We repeat these scores at weeks 4, 8 and 12; it is how we see your progress clearly, beyond the scale.

Week 0: Energy
0 low, 10 great
Week 0: Brain fog or focus
0 low, 10 great
Week 0: Mood
0 low, 10 great
Week 0: Anxiety or feeling on edge
0 none, 10 severe
Week 0: Stress
0 none, 10 severe
Week 0: Sleep quality
0 low, 10 great
Week 0: Waking refreshed
0 low, 10 great
Week 0: Cravings
0 none, 10 severe
Week 0: Hunger between meals
0 none, 10 severe
Week 0: Bloating
0 none, 10 severe
Week 0: Water retention
0 none, 10 severe
Week 0: Stomach burning
0 none, 10 severe
Week 0: Skin overall
0 none, 10 severe
Week 0: Joint aches
0 none, 10 severe
Week 0: Headaches
0 none, 10 severe
Week 0: Motivation
0 low, 10 great
09

Your lifestyle

Describe what usually happens, not your ideal routine.

Sleep quality
Bed and wake times consistent?
Trouble falling asleep?
Waking during the night?
Does itching keep you awake?
Screens in the last hour before bed?
Do you drink coffee on an empty stomach?
Is your last coffee before 3 p.m.?
Black tea, coffee or matcha after 3 p.m.?

Why I ask. Caffeine after 3 p.m. is still in your system at bedtime, where it disturbs your sleep and recovery. Coffee, black tea or matcha with or soon after a meal also blocks some of the iron you would absorb from that meal, which matters for your energy, hair and skin.

Do you reach about 2.5 L of fluids per day?
Headaches, dry mouth, dizziness or dark urine?
Sun exposure on your skin
Do you notice changes in your skin after drinking alcohol?
Average stress level
10

Movement and eating routine

Your day is mostly
How does training usually feel?
Breakfast within 1 to 2 hours of waking?
Three proper meals most days?
Protein in each meal?
Two fruit and three vegetable portions a day?
Eating out or takeaway
Eating late (within 2 hours of bed)?
Eating when stressed, bored or emotional?
11

Foods you love and foods to avoid

Your plan should be built around food you actually enjoy. Tick how you feel about each cuisine, and tell me your favourite dishes.

Arabic (hummus, falafel, shawarma, kabsa, mansaf, maqluba, tabbouleh, fattoush, kibbeh, mezze, kofta)
Italian (pasta, risotto, pizza, lasagne, minestrone, caprese, grilled fish)
Spanish (paella, tortilla, gazpacho, tapas, grilled seafood)
French (quiche, ratatouille, omelettes, crêpes, niçoise salad, onion soup)
Mexican (tacos, burritos, fajitas, enchiladas, guacamole, chilli, burrito bowls)
Indian (dal, tikka, butter chicken, biryani, chana masala, tandoori, raita)
Turkish or Greek (kebabs, grilled meats, Greek salad, souvlaki, tzatziki, lentil soup)
Romanian or Eastern European (ciorbă, sarmale, mici, stews, polenta, grilled meats)
Asian (sushi, Thai curry, stir-fries, poke bowls, ramen, pho, teriyaki)
American or fast food (burgers, fries, fried chicken, wings, pancakes, bagels)
Do you prefer
Spice level you enjoy
Allergies and intolerances
12

Diet history, restriction and fasting

Past diets and fasting shape your metabolism, hormones, hair, gut and your relationship with food today. There is no judgement here; honesty helps me keep you safe.

How you eat now
Diets you have tried before
Have you ever fasted?
Religious fasting
Eating disorders, past or present
Episodes of eating a large amount in a short time with a feeling of losing control (binge eating)?
Ever diagnosed or treated for an eating disorder?

If any of this is active now, I will ask you to work alongside your doctor or an eating-disorder specialist. Coaching supports treatment rather than replacing it, and this is never a reason for me to turn you away.

Ever eaten very little (under 1,200 kcal) for weeks?
Cut out whole food groups (carbs, fats, dairy)?
Lost your period or hair while dieting?
Used laxatives, diuretics or detox teas for weight?
Exercised to burn off food or make up for eating?
Feel guilty or anxious after eating?
13

Your measurements

Use a soft measuring tape. Stand relaxed and breathe normally. Measure on bare skin or fitted clothes, keep the tape parallel to the floor and do not pull it tight. Same method, same time of day, every time. If you cannot take a measurement today, tick “I can’t measure this now” and send it later.

Bare feet standing flat and hip-width apart on a digital bathroom scale.

Weigh yourself in the morning, after using the toilet and before eating. Same scale, same spot on the floor.

Woman standing barefoot with her back against a wall and a level headpiece resting on top of her head to mark her height.

Stand with your back against a wall, no shoes, heels together, looking straight ahead. Rest a flat book or a ruler on your head, level against the wall, and measure from the floor to its underside.

Pink measuring tape held level around the narrowest part of the waist, above the belly button.

Narrowest part of your waist, usually 2 to 3 cm above the belly button. Breathe out normally, do not pull your stomach in.

Pink measuring tape held level around the abdomen at belly-button level.

Around your waist exactly at belly-button level, with the tape passing over it. This measurement usually changes the most.

Pink measuring tape held level around the fullest part of the hips over fitted shorts.

Around the fullest part of your hips and buttocks, feet together, tape level all the way round.

Pink measuring tape held level around the fullest part of the chest over a sports top.

Around the fullest part of your chest, across the nipple line, arms relaxed at your sides.

Pink measuring tape around the upper thigh, just below the crotch.

Around the fullest part of your thigh, just below the buttock fold, standing with weight on both feet.

Side view of a relaxed upper arm with a pink measuring tape level around it, halfway between shoulder and elbow.

Around the fullest part of your upper arm, halfway between shoulder and elbow, arm relaxed and hanging, not flexed.

Close-up of a pink measuring tape resting level around the lower neck, above the collarbones.

Around your neck just below the Adam’s apple (the bump at the front of the throat), tape level and resting lightly on the skin. Look straight ahead with your shoulders relaxed.

so we compare like with like next time
Example progress photo: full body from the front, standing relaxed in a black sports top and fitted shorts.
Front
Example progress photo: full body from the side, arms relaxed, in a black sports top and fitted shorts.
Side
Example progress photo: full body from the back, standing relaxed in a black sports top and fitted shorts.
Back

Progress photos: please don’t skip them. Take 3 photos: front, side and back. Stand relaxed in a natural posture, feet hip-width apart, in good light against a plain background, head to toe in frame. Optional: close-ups of any skin concern, same spot and light each time. Take them for yourself, even if you never show them to me: in the first month the scale often does not move, but your body does. Shape, posture, waist, skin and body composition change first, and the photos are how you will see it. Repeat them every 4 weeks in the same place, light and clothes.

14

Blood tests to share

Please email your most recent results as clear photos or PDFs, with the date next to each. Your doctor interprets them; I use their findings to plan your nutrition. If something is missing, don’t worry: I will tell you what else we may need.

haemoglobin, haematocrit, RBC, WBC, platelets
ferritin, serum iron, transferrin or TIBC, transferrin saturation
sodium, potassium, chloride, calcium, magnesium, creatinine or eGFR
TSH, free T4, and free T3 in some cases
fasting glucose, HbA1c, fasting insulin (optional but useful)
CRP, sometimes ESR
Hormone panel, if relevant or available
Also useful, if available

Cycle-day hormones are usually tested on days 2 to 5 of your period unless your doctor says otherwise. Results are reviewed for nutrition planning, not diagnosis; anything out of range should be discussed with your doctor.

15

7-day food journal

For 7 consecutive days, track everything you eat and drink in MyFitnessPal, covering both weekdays and the weekend. Do not try to eat better this week: I want your real baseline, not a perfect version. Export your diary or send screenshots by email, then fill in your averages below.

16

Your Whoop band

Whoop is my preferred tracker: screen-free, comfortable 24/7, and good at measuring sleep, stress, strain and recovery. Wear it snug, a finger-width above the wrist bone, and turn on cycle tracking. Log alcohol, late meals, stress and supplements in the Journal, and after 7 days email me screenshots of your weekly overview. Sleep consistency matters as much as sleep hours: going to bed and waking at the same times is what settles your hormones and appetite.

how regular your bed and wake times were; Whoop shows it under Sleep
StrainMeaningRecoveryMeaning
0 to 9 lightRest and active recovery67 to 100 percent, greenReady to push
10 to 13 moderateMaintains fitness34 to 66 percent, yellowTrain moderately
14 to 17 highBuilds fitness0 to 33 percent, redPrioritise rest
18 to 21 all outNeeds extra recoveryLow recovery often lines up with stress, poor sleep or alcohol

Whoop needs a few days to learn your baseline, so the first 3 to 4 days may be less accurate. Whoop is membership-based; if you already own another tracker, let me know before you buy one.

17

Your programme

What is included

Full personalised nutrition strategy · weekly check-in review and ongoing follow-ups · continuous adjustments based on your body’s response · nutrition adjusted to your doctor’s blood-test findings and supplement suggestions agreed with your doctor · direct support between check-ins, with voice notes or calls when needed.

How we work

No rushing: we give your body time to adapt. Gradual and structured, with changes based on your response. Aligned with female physiology: supported, not forced. A long-term view: skin and gut often take 4 to 6 months, though you will usually notice progress much sooner.

Investment

Prices for the 16-week programme are on its own page: Programme details and pricing. Supplements and blood tests are separate.

Your rights

You can withdraw within 14 days of signing your agreement. If you asked us to start within those days, you pay a proportionate amount for what was already provided. Full terms are in your coaching agreement.

18

Your agreement

Please read and tick each line.

Your answers are sent to contact@withmenutrition.com by email when you press Send on the last step. Nothing is stored on this device unless you turn on “Save my answers on this device” at the top of the form; then it is kept only in this browser for up to 30 days and you can delete it at any time. Questions marked optional can be left blank; if you prefer not to email blood-test results, you can show them during your first call instead.

Send it to your coach

Write your full name and the email you use with WITH ME. Your answers go straight to contact@withmenutrition.com and nowhere else.

Please add your full name and email, and tick the consent box.

Checklist, send before our first review

This intake (sends itself) · measurements (section 13) · blood test results with dates, by email · 7-day MyFitnessPal export, by email · 7-day Whoop screenshots, by email · photos of medication and supplements, by email. Thank you for taking control of your health. Consistency, not perfection.

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