Current Nutrition Client

Check in Form

2025 CHECK IN POLICY

*DEADLINE: Thursdays @ 5:00pm

*Complete ALL fields. Do not leave information blank.

*Blank or Incomplete forms will not be answered with a program update.

*Pictures are highly recommended but NOT required for a complete check in.

*Body Measurements are recommended.

Business Hours for Email/Contact

Monday - Friday

8am-7pm

jandasimons.fitness@gmail.com

Phone

785-220-2755

Social Media

Check-in Date:

First Name

Last Name

Phone

Identify your personal goals associated with your fitness journey.

Current Weeks Weight

Are you taking Ozempic/Semaglutide/Monjaurno/or any other weight loss shot/injection/supplement/medication?

How much cardio were you assigned to this week?

Type & Duration of Cardio (ex. Incline Treadmill - 20 min)

Are you feeling tired/sluggish/low energy during the day? If so, when?

Are you maintaining energy during your workout/cardio?

How many hours of sleep are you getting?

Did you follow the written meal plan this week?

Please list any meals/foods/beverages that you consumed that were not part of your nutrition plan this week:

Please list any foods you are craving: (be specific)

List any meals/foods you WANT TO KEEP on your meal plan this week. Keep in mind consistency is key to getting the BEST results!

List any meals/foods you DO NOT WANT TO KEEP on your meal plan this week. These meals/foods will result in a CHANGE to your plan and may require your coach to change other meals to maintain your macronutrient range.

Are you experiencing hunger during the day? If so, please identify specific times of the day that you are most affected by this.

Are you having regular digestive habits including bowel movements? Please identify if you are having constipation/loose stools.

How many OUNCES of water are you drinking daily? Please identify if there are any days of significant decrease/increase in water intake.

Please list any supplements/products you have added or removed to your routine (do not relist items you take regularly):

If you have been sick, please list any medications including over the counter that you have been taking:

List any deviations from the plan your coach should know. This may include unforseen stressful situations from your week that could have elevated your cortisol levels.

Please also include any events/outings you may have in the next week so your coach can help guide you. (weddings/dates/anniversaries/birthdays)

Shoulders

Chest/Bust (widest point)

Waist (narrowest point)

Glutes (widest point)

Left Thigh

Left Bicep

Right Bicep

Left Calf

Right Calf

Right Thigh

By checking this box, I authorize my photos to be used as transformation examples including use on the website.

FRONT PICTURE

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SIDE PICTURE

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BACK PICTURE

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