Health and Lifestyle Questionnaire
Fill out the form below so I can understand your needs and create a plan tailored just for you.
Customer Details:
Full name
*
Date of Birth
*
-
Month
-
Day
Year
Age:
E-mail
*
example@example.com
Gender?
*
Female
Male
Other
If selected “other” please write below your preferred pronouns:
Height:
*
Current weight (kg)
*
Current waist circumference
*
Inner thigh circumference
(cm)
Bicep circumference (relaxed position)
(cm)
Do you suffer from any of the following?
*
Are you currently pregnant or breastfeeding
Diabetes type I or II
Gastrointestinal issues
Food allergies / intolerances / preferences
Raised cholesterol levels
Do you smoke?
If you have ticked any of the above, please elaborate in the space below:
If you have any food allergies, intolerances or preferences, please state here:
What are the goals you hope to achieve whilst working with me?
*
Can you think of any situation/people that may prevent you from achieving these goals?(indicate below what/who they are)
Typically how many meals and snacks do you usually have per day?
*
How would you class your exercise per day?
*
Light
Moderate
Heavy
Advanced/Athlete
If you exercise, what are your main forms of exercise?
Do you struggle with energy crashes? If yes, what time typically each day do you notice this?
Signature
*
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