Diet Evaluation
Name
First Name
Last Name
Age
Current Weight
Height
Do you have any pre-existing medical conditions? (e.g., diabetes, hypertension, heart disease, etc.)
Yes
No
Are you currently taking any medications?
Yes
No
If Yes Please List:
Do you have any allergies?
Yes
No
If Yes Please List:
Do you have any dietary restrictions? (e.g., gluten-free, lactose intolerant, vegetarian, etc.)
Yes
No
If Yes Please List:
How often do you exercise?
Rarely
Occasionally
Regularly
Frequently
What types of exercise do you engage in? (e.g., weightlifting, cardio, yoga, etc.)
How many hours of sleep do you get on average per night?
Do you smoke?
Yes
No
How many meals do you eat per day?
Do you snack between meals?
How much water do you drink daily?
What are your favorite foods? (Please list)
Are there any foods you dislike or avoid? (Please list)
How often do you eat meat? (e.g., daily, weekly, rarely)
How often do you eat fruits and vegetables? (e.g., daily, weekly, rarely)
What are your primary goals for your diet while on Programs with Reverse? (e.g., muscle gain, fat loss, increased energy, overall health)
Are there any specific foods or nutrients you want to avoid in your diet?
Are there any specific foods or nutrients you want to include in your diet?
Do you have any other comments or information that might be relevant for creating your custom diet plan?
Submit
Should be Empty: