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The Blueprint
The Process
Begin Your Blueprint

Begin Your Nourish Blueprint

This questionnaire gathers the information needed to create your personalized nutrition plan.

The Nourish Blueprint is a one-time investment of $247 and is designed to be followed and repeated over a 90-day period.

Please answer thoughtfully and honestly.

THE NOURISH BLUEPRINT

Intake Questionnaire

First name*

Last name*

Email*

Health & Body Context

This information helps ensure your Nourish Blueprint

is built appropriately and responsibly.

Current weight (optional)

Height*

Which best describes your current goal direction?*

Lose body fat

Gain weight

Build muscle

Maintain current weight

Improve energy & consistency

Are there any medical conditions, injuries, or medications that may affect your nutrition or activity levels?

I understand this program does not provide medical advice and is not a substitute for care from a licensed medical professional.

Life Stage & Context

This helps create a plan that supports your current season of life.

Which best describes your current life stage? (Select all that apply)*

I have a regular menstrual cycle

I have an irregular menstrual cycle

I am perimenopausal

I am postmenopausal

I am currently pregnant

I am postpartum

I am currently breastfeeding

None of the above

If applicable, how many children do you have?

Do you notice changes in appetite, energy, or cravings throughout the month?*

Yes

Sometimes

Not really

Not sure

Goals & Focus

Understanding your primary focus helps shape your Nourish Blueprint.

What are your primary nutrition goals right now? (Select all that apply)*

Fat loss

Weight gain

Building muscle

Supporting training or performance

Improving energy

Creating consistency

Improving overall wellbeing

Other

If you had to choose one main focus for the next 90 days, what would it be?*

Daily Routine & Eating Pattern

Your current schedule helps determine meal timing, structure, and overall plan design.

How would you describe your current daily schedule?*

Very structured

Somewhat structured

Busy and variable

Overwhelming or inconsistent

What does your current eating schedule look like most days?*

I eat 3 structured meals

I eat 2 meals per day

I snack throughout the day

I skip meals frequently

It varies day to day

Around what time do you eat your meals?

Movement & Activity

This helps determine overall intake and recovery needs.

How many days per week are you intentionally active?*

0-1 days

2-3 days

4-5 days

6+ days

What types of movement or training do you currently do? (If any)

Nutrition Experience

Understanding your history helps create a realistic plan.

Have you followed a structured nutrition or macro-based plan before?*

Yes, consistently

Yes, on and off

No, this is new to me

What has felt hardest to maintain in the past? (Select up to two)*

Consistency

Knowing how much to eat

Getting enough protein

Planning meals

Time

Stress or emotional eating

Other

Food Preferences

Your plan should feel realistic and aligned with what you’ll actually eat.

Do you have any food allergies, intolerances, strong dislikes, or dietary preferences I should consider?*

How do you feel about repeating meals throughout the week?*

I prefer repetition

I’m okay with some repetition

I prefer variety

Readiness & Commitment

The Nourish Blueprint is designed to be followed and repeated over a 90-day period.

Does committing to a 90-day structure feel realistic for you right now?*

Yes

Mostly

I'm unsure

What would success look like for you after 90 days?*

Is there anything else you’d like me to consider while creating your Nourish Blueprint?

Her Nourish Blueprint

devyn@hernourishblueprint.com

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