Male Nutrition Questionnaire

NUTRITION QUESTIONNAIRE (MALE)

Thank you for taking the time to complete this survey. In order to get an idea of where you are at with nutrition, please answer the following questions honestly. Of course, no judgement here! All of your answers are kept 100% confidential.
Name*

First NameLast Name
Email:*
Instagram handle:*
Facebook name:*
Phone:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Age:*
Sex*

MaleFemaleOther
Occupation:*
Height:*
Weight:*
If you have recently had it measured, what is your body fat percentage?
Are you currently under the care of a healthcare provider for any diseases or health-related conditions, or have you ever been diagnosed with any diseases or health-related conditions?*

YesNo
If yes, please list them.
Do you have any food allergies?*

YesNo
If yes, please list them.
Do you have any food sensitivities / intolerances?*

YesNo
If yes, please list them.
Do you have any other dietary restrictions?*

YesNo
If yes, please list them.
Current medications:*
Please list any supplements you take.*
Have you ever consulted a dietician or nutritionist before?*

YesNo
If yes: How long ago? Did they help you? Why or why not?
Are you currently on any type of specific diet or nutrition plan?*

YesNo
If yes, what kind of diet or nutrition plan are you currently on?*

KetoPaleoWhole 30Low carbVeganVegetarianPescatarianLow fatIntermittent fastingWeight WatchersSouth BeachLow FODMAPNone of the aboveOther
What types of diets have you tried in the past? Please list them all.*
Please describe any success you had on these diets.
How did you feel while you were on these diets?
How healthy do you currently feel?*
How much water (approximately) do you consume on a daily basis?*
Do you drink soda, juices, coffees, energy drinks, or other beverages sweetened with SUGAR?*

YesNo
Do you drink diet soda, juices, coffees, energy drinks, or other beverages sweetened with ARTIFICIAL sweeteners / sugar substitutes?*

YesNo
How often do you drink alcohol?*

NeverOnce a month or less2-4 times a month2-3 times a week4 or more times a week
On a typical day that you drink alcohol, how many alcohol-containing drinks do you consume?*

1-23-45-67 or moreOther
How often do you eat a full serving of fruits and/or vegetables?*

NeverOnce a week or less2-3 times a week4-6 times a weekEvery dayOther
Do you ever make smoothies at home?*

YesNoOther
Do you eat refined-carb "white" foods (ie - white bread, pasta, sugar, muffins, cakes, cookies, pastries, cereals, pies, chips, white potatoes, white rice, etc.)?*

YesNo
Do you consume dairy (ie - milk, cheese, yogurt, ice cream, etc.)?*

YesNo
Do you consume gluten-containing foods/drinks (products that contain wheat, barley, rye)?*

YesNo
Do you consume red meat (ie - beef, lamb, pork) and processed meat (ie - ham, bacon, sausage, salami, etc)?*

YesNo
Do you consume fried foods?*

YesNo
What kinds of food do you like?
What kinds of food do you dislike?
Do you experience any of the following symptoms?*

Abdominal pain and/or bloatingHeartburnConstipationDiarrheaHeadacheRunny noseRashJoint painNone of the above
If yes to any of the above symptoms, how often?
Do you suffer from any of the following?*

DepressionAnxietyBrain fogStressTensionIrritabilityNervousnessFatigue / TirednessDifficulty sleepingNone of the above
How often do you dine out in a week?*
Do you cook for yourself?*
Are you responsible for cooking for other people? How many people? Any children?*
How many meals (including snacks) do you consume in a day?*
Do you often have dinners late at night?*
Do you snack after dinner?*

YesNo
On average, how many hours of sleep do you get per night?*
How often do you exercise?*

NeverOnce a week or less2-3 times a week4-5 times a week6 or more times a week
What kind of exercise do you do?*

WalkingRunningHikingCyclingRowingYogaPilatesDanceStrength / Resistance trainingGroup fitness classesOther
What is your activity level?

Sedentary: Activities of daily living only. No moderate or vigorous activities. Spend most of the day sitting (ex: desk job, bank teller).Lightly Active: Activities of daily living, plus daily exercise equal to walking 30 minutes (or 15-20 minutes of vigorous activity). Spend a good part of the day on your feet (ex: teacher, sales person).Active: Activities of daily living, plus daily exercise equal to walking for 1.75 hours (or 50 minutes of more vigorous activity). Spend a good part of the day doing physical activity (ex: food server, mail carrier).Very Active: Activities of daily living, plus daily exercise equal to walking 4.25 hours (or 2 hours of more vigorous activity). Spend most of the day doing heavy physical activity (ex: bike messenger, carpenter).
What are you primarily looking for in a nutrition plan?*

A rigid, restrictive plan to help me lose as much weight as possible, as fast as possibleA plan to help me build healthy habits over timeA plan that sets me up for long-term success in my health and fitness goalsAccountabilitySustainable weight lossIncreased strength and lean muscleA plan that gets my body to stop resisting weight lossTo achieve the lowest possible level of body fatTo detox my bodyTo improve my digestive systemA plan that teaches me how to eat whole foods for a healthy lifeTo improve my wellbeing, vitality, and energyOther
Please describe your current nutrition knowledge level. *
What are your health and fitness goals? Please be as specific as possible.*
What length of time are you willing to commit to achieve your goals?*

Less than 1 month1-3 months4-6 months7-9 months10-12 months12+ monthsOther

How ready are you to make the necessary changes to achieve your goals?

	1	2	3	4	5

1 is Not ready, 5 is Extremely ready

What do you need the most help with in nutrition?*
Why do you want to improve your nutrition?*
Do you currently track/log your food & liquid intake daily?*

YesNo
If yes, what method or app do you use?
Are you willing to commit to tracking/logging your daily food & liquid intake?*

YesNo
Should be Empty:

NUTRITION QUESTIONNAIRE (MALE)