Nutrition Intake Form | Viking Wellness Solu

First name

Last name

Phone

Birthday

Month

Day

Year

Sex assigned at birth

Male

Female

Do you currently take any hormones (prescribed or not)?

No.

Yes, Testosterone-based.

Yes, Estrogen-based.

Other

Please detail hormone use (type, amount, frequency, duration of use, etc.)

Do you have any medical conditions that affect nutrition?

Yes

Please detail any conditions (if any).

Please list any vitamins, OTC medications, supplements, or lifestyle enhancements (peptides, AAS, etc.) that you take regularly along with dose, frequency, and duration of use. If you don't take anything, please write "None"

Primary nutrition goal:

Dietary constraints:

List any food allergies or intolerances.

Preferred amount of meals/day (including snacks):

Typical daily schedule

Current nutrition approach:

Briefly describe how you currently eat (typical foods, tracking or not, etc.). If you keep a food log, please input your log for three different days here.

What is your biggest nutrition struggle?

I understand this nutrition plan is for general health and performance purposes and does not replace medical advice. I have disclosed all relevant health and dietary information.