Nutrition Consultation Questionnaire
Please fill out this form to help me understand your nutrition goals and needs. All responses will remain confidential.
Full Name
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
What are your main nutrition goals?
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Weight Loss
Muscle Gain
Improved Energy
Better Digestion
General Health
Other
How motivated are you to make changes to improve your health?
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1 (Unmotivated)
2
3
4
5
6
7
8
9
10 (Highly Motivated)
What nutritional services offered are you interested in?
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Nutritional guidance (food choices, meal ideas)
Macro tracking
Grocery store help / in person shopping trip
Nutrition label deciphering
Meal prep / planning
My nutrition knowledges is:
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Not so good, I want to learn more
Average
Good
Very Good
Please explain your goals and what you’re looking for with a nutrition coach in depth.
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Do you have any food allergies, intolerances, sensitivities, or adverse food reactions? Please list.
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Have you ever done a food sensitivity test? Or are you interested in doing one?
*
What does your current diet look like?
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Low Carb
Low Fat
High Protein
Vegan
Vegetarian
Keto
Carnivore
No current diet
Other
Describe your typical daily food and fluid intake.
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How many meals do you eat per day?
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How many meals and snacks do you eat daily? Who does the cooking & grocery shopping in your home?
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Do you meal plan or prep? Do you read food labels, and what do you look for?
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What are your favorite foods, disliked foods, and any food restrictions?
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How many meals do you eat away from home per week? What types of establishments do you frequent?
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Do you ever eat for reasons other than hunger? Please select all that apply.
Relaxing/Reward
Upset/Mad
Boredom
Tired
Stress/Anxiety
Social Custom
Other
Do any of these habits apply to you? Please select all that apply.
Eating large portions
Skipping meals often
Use a sugar subsitute
Eating too much sugar
No exercise
Consume juice, sweet tea, or soda
Eating too much fatty foods
Don’t drink enough water
Drink diet beverages
Consume too much salt
Eat when not really hungry
Eat too fast/not mindfully
Eat a lot of fast food
Use frozen meals
Eat a lot of junk food
Eat little/no fruits & vegetables
Other
How much water do you drink daily?
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Do you drink caffeine?
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Yes
No
If yes, please list types of caffeine.
Do you consume alcohol?
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Yes
No
If yes, please list frequency and how much.
Do you take any supplements?
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Vitamins
Minerals
Protein Powder
Herbal Supplements
None
Other
Please list any & all supplements and vitamins you currently take or would like to talk about/try. Please specify.
*
How many average hours of sleep do you get a night?
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<4
5-6
7-8
9+
Do you have any medical conditions related to nutrition?
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Do you have or have you had an eating disorder?
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Yes
No
If yes, please describe. If no, please write N/A.
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Submit
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