KFF Introductory Questionnaire

Full Name *

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

Male Female Transgender Male Transgender Female
Date of Birth *

Month Day Year
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-fat low-carb high-protein Intermittent Fasting Vegetarian Vegan I eat whatever I want
Approximately how many hours of sleep do you get each night?
What is your average stress level?

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

Weight Loss Weight Gain Weight Maintenance Improve Energy Improve Athletic Performance
When were you hoping to begin a program?

Month Day Year
Date
What challenges do you face in maintaining a healthy diet?

Too Busy Lack of Energy Convenience Foods Emotional Eating Sweet Tooth Social Situations Lack of Information Picky Eater
Have you tried a nutrition program in the past?

Yes No
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?

Yes No
Do you drink alcohol?

Yes No
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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