REGINA SIMMONS
Contact@ReginaSimmonsOnlineFitness.com
www.ReginaSimmonsOnlineFitness.com
Initial Nutrition and General Health Questionnaire
Your Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Your E-mail Address
*
example@example.com
Questionnaire
What are your primary wellness & nutrition goals? (fat loss,general health, build habit, energy, muscle gain)
What do you feel is your greatest nutrition challenge right now?
What is your work schedule?
(Shift work, long hours, remote)
What are your current eating habits?
Home-cooked meals,take-out, fast food, or a mixture
What does your bevarage intake look like?
Please list your food preferences and restrictions below. Are you open to trying new foods?
Do you have any food allergies or intolerences?
Are you currently taking medications or supplements?
Are you ready and willing to participate in accountabilty check-in calls?
Do you understand that this nutrition guidance is for general wellness and not for medical nutrition therapy?
*
Submit
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