Nutritional History Questionnaire
TOTAL HUMAN COACHING
Full Name
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First Name
Last Name
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
*
example@example.com
What is the goal of your nutrition plan? e.g. performance, body composition, general health.
*
Past/Current Nutrition
What have you tried/done with your nutrition over the past 5 years? e.g. keto, calorie restricted meal plans, flexible dieting
What has AND has not worked for you in the past?
Describe an average day of nutrition for you, and state how long this has been for. Include all foods, liquids, sauces, etc e.g. Breakfast: 7am 2 eggs, 3 bacon rashers, coffee with dash of milk and sugar Lunch: 12pm 200g mince, 2 wraps, heaps of salad
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What supplements, if any, are you taking?
Do you have any food intolerances? e.g. lactose intolerance, coeliac.
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How do you think your current diet is affecting you? e.g. feeling tired/energetic, gaining/losing body weight
Food Preferences
What meats DO you like?
What meats DON'T you like?
What vegetables/salads DO you like?
What vegetables/salads DON'T you like?
What fruits DO you like?
What fruits DON'T you like?
What grains DO you like?
What grains DON'T you like?
What meals DO you like?
What meals DON'T you like?
Is there anything that you feel MUST be included in your diet for your own sanity? e.g. toast at breakfast, dessert after dinner, milk in coffee
How many meals do you consume daily? e.g. 3 meals and 3 snack or breakfast/lunch/dinner
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How many times a day do you want to OR can you realistically eat and when? e.g. 4 times - breakfast meal, lunch meal, afternoon snack, dinner meal
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Do you believe you would be more adherent to a strict meal plan (eating the same things daily), or flexible dieting (tracking food, more effort BUT freedom of flexibility)?
*
Please Select
Meal plans
Flexible dieting
Current daily intake total in calories (if known)
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Current Body Composition and Activity
Gender
*
Male
Female
Age
*
Weight (kg, morning fasted weight prefered)
*
Height (cm)
*
Body fat %
Front, rear and side relaxed photos to assess body fat levels (optional)
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If done in the last 3 months: Fasted Dexa or Inbody/Tanita scan data: (option below to upload photo of data)
Fasted Dexa or Inbody/Tanita scan data photo upload
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Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medical conditions or symptoms?
Yes
No
Please list them.
Your current job activity e.g. labourer - 10 hours/day in sun on tools, office worker - 8 hours/day in office AC and sitting down
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Your current lifestyle activity e.g. walking dog, going to the beach, nature hike AND/OR non-exercise related steps per day
Your current exercise and routine e.g. 3x1 hour weights sessions in gym Mon, Wed, Fri; 2x 30min runs Tues & Thurs
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What are your short term goals (1-6 months)?
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What are your long term goals (6month-2+years)?
*
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