Meal Prep Consultation Questionnaire

Full Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

years

Height

cm

Weight

KG

How did you hear about us?

What is your daily activity level?

Do you follow a regular working schedule? Do you work days, afternoon or nights?

Do you have any medical problems?

If you are on any medications, please list them.

What additional therapies are being undertaken for the given health problem(s)?

I.e., IV therapy, Dialysis, etc.

Do you have any injuries?

What additional therapies are being undertaken for the given injury?

I.e., Physical therapy, Occupational therapy, etc.

What are your short term goals?

What are your long term goals?

What following goals speak to you the most?

Are you experiencing any stresses or motivational problems?

If yes, please explain:

If yes, what do you feel can assist you with achieving your goals?

Do any diseases run in your family?

If so, please explain:

Do you suffer from diabetes, asthma, high or low blood pressure?

if yes please list:

Do you have any food allergies? If yes, please include reaction:

If so, please include reaction

Your current diet could be best characterized as:

Your ideal diet would be best characterized as:

What sources of protein do you enjoy?

What protein sources will you not indulge in?

What sources of carbohydrate do you enjoy?

What carbohydrate sources will you not indulge in?

What vegetables do you enjoy the most?

What vegetables do you not enjoy?

What fruits do you enjoy the most?

What fruits do you not enjoy?

What are your favorite snacks?

What is your favorite food?

What is your least favorite food?

Please select the condiments that you enjoy:

How would you like your meals seasoned?

How many meals a day are you looking to have prepared for you?

I.e., One, Two, Three, etc.

How long of a meal prep would you like prepared for you?

I.e., One day, Three days, Five days, Seven days, etc.

Would you like snack options included in your meal prep?

If yes, please indicate how many snacks per day:

Please add any additional information below:

I AGREE TO THE ABOVE TERMS & CONDITIONS!