KFF Introductory Questionnaire

Full Name*

First NameLast Name
Email*
example@example.com
Gender*

MaleFemaleTransgender MaleTransgender Female
Date of Birth*

MonthDayYear
Age
years
Height*
Weight*
lbs
Whats the activity level at your job?

none(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Your current diet could be best characterized as:

low-fatlow-carbhigh-proteinIntermittent FastingVegetarianVeganI eat whatever I wantOther
Approximately how many hours of sleep do you get each night?
What is your average stress level?

ChillI get irritated sometimes but I don't let it get to meModerateHeavyI'm going to rip the head off of the next person who crosses me
What are the primary goals you hope to achieve?

Weight LossWeight GainWeight MaintenanceImprove EnergyImprove Athletic PerformanceOther
When were you hoping to begin a program?

MonthDayYear
Date
What challenges do you face in maintaining a healthy diet?

Too BusyLack of EnergyConvenience FoodsEmotional EatingSweet ToothSocial SituationsLack of InformationPicky EaterOther
Have you tried a nutrition program in the past?

YesNo
If so, describe it (or them)
Why did you stop following the plan?
If you have any diagnosed health problems please list the condition(s).
If you are on any medications or supplements, please list them.
Do you have any allergies, dietary restrictions, or cultural considerations surrounding nutrition? Please list/describe them.
Do you currently exercise in any form? If so, how often?
Do you have any medical conditions that prevent you from getting exercise? If so, please describe.
Are you a current cigarette smoker?

YesNo
Do you drink alcohol?

YesNo
Is there anything else Steve should know about your history or physical condition that you are aware could influence or should influence your nutritional habits?
You're done! Steve will review your answers and contact you regarding program options.

If you have any questions in the meantime you can reach him at steve@koskisfoodfight.com
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