Nutrition Questionnaire
Full Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your Date of Birth?
*
-
Month
-
Day
Year
Date
Age:
*
What is your gender?
*
Male
Female
N/A
How tall are you? (ie: 4'11", 5'9", 6'2")
*
How much do you weigh? (in LBS)
*
What are your nutrition goals?
*
Lose Weight
Lose Fat
Build Muscle
Gain weight
Maintain Current weight
Other
What is your activity level?
*
Desk job/little to no exercise
Light Exercise 1-3 days/wk
Moderate Exercise 3-5 days/wk
Hard Exercise 6- days/wk
Physical job & Hard daily exercise
MEDICAL/HEALTH HISTORY
Please list any past or current medical conditions that you have or are currently being treated for
*
List any Medications you are currently taking:
*
Do you Smoke?
*
Yes
No
If yes, how often/much?
Do you Drink Alcohol?
*
Yes
No
If yes, how often/much?
Do you have any food allergies? (ie results in hives, rash etc)
*
Yes
No
Not Sure
Please list them.
Do you have any food sensitivities? (ie causes bloating, inflammation etc)
*
Yes
No
Not Sure
Please list them.
Any additional considerations?
Are you currently taking any supplements (ie: Vitamin D, Calcium, Protein Powder/shakes, Sports Supplements?)
*
Yes
No
Please list them.
Please rate your stress: (1 = Low; 10=high)
*
1
2
3
4
5
6
7
8
9
10
How do you cope with stress:
FOOD & NUTRITION
How many times do you typically eat?
*
How many meals would you like in your nutrition plan? (Meals and Snacks)
*
1
2
3
4
5
6
Do you consume caffeinated beverages on a regular basis?
*
Coffee
Tea
Soda
Energy Drinks
N/A
Do you avoid any of the following foods:
*
Red Meat
Poultry
Fish
Dairy (milk/Cheese)
Vegetables
Fruits
Fried Foods
Breads
Grains
Fast Foods
Sweets
Alcohol
Fats/Oils
Check the dietary restrictions or diet you are on if any:
*
Lactose Free
Vegan
DASH
Vegetarian
Low Carb
Gluten Free
Mediterranean
Other
Are there foods you hate or do not eat?
*
Yes
No
If yes, what foods do you not eat?
*
What foods do you especially like?
*
WEIGHT HISTORY
Has your appetite changed recently?
*
Yes
No
If yes, please describe:
Have you recently gained or lost weight?
*
Yes
No
If yes, please explain whether it was a gain or loss and what led to the change in weight.
Have you ever had concerns about your weight?
*
Yes
No
Underweight
Overweight
Comment:
Have you ever tried to lose/gain weight in the past?
*
Yes
No
If yes, please describe:
What is your goal weight?
*
Overall, how satisfied are you with the physical appearance of your body?
*
Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
Medical Weight Loss
Are you participating in a medical weight loss program?
*
Yes
No
What are you on and who is the Provider?
If no, would you like more information about our medical weight loss partnership?
*
Yes
No
PHYSICAL ACTIVITY
Do you currently engage in physical exercise?
*
Yes
No
If yes, How often (times per week). how long (minutes per session), type of activities:
Please rate the average intensity of your workouts (select one):
*
Light (walking slowly, sitting, standing)
walking (briskly, heavy cleaning, light bicycling)
Vigorous (hiking, running, fast cycling, most team sports, weight lifting)
Do you have any current injuries, ailments or are under medical supervision for an injury?
*
Yes
No
If yes, please describe the injuries and limitations associated with those injuries/ailments:
Are you interested in personal training information?
*
Yes
No
Maybe (more info needed)
Are you interested in online fitness coaching? (not 1-on-1 personal training)
*
Yes
No
Maybe (more info needed)
NUTRITION GOALS
What nutrition goals do you have?
*
What eating habits would you like to work on?
*
How IMPORTANT is it to you to make changes in your nutrition habits?
*
1=unimportant; 10=Very Important
How CONFIDENT are you in your ability to improve your nutrition habits?
*
1=Not Confident; 10=Very Confident
Please provide any additional information you feel may be important for me to know about your health, habits, nutrition etc.
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