Lifestyle and Nutrition Counseling
General Information
Name
*
First Name
Last Name
Email
*
example@example.com
Height
*
Current body weight
*
Age
*
Medical History / Health Status
Medical conditions and medications (please describe condition and medication)
Allergies or food intolerances
*
None
Lactose
Gluten
Histamine
Fructose
Celiac disease
Other
Do you have digestive issues?
*
No
Occasionally
Frequently
Always
Number of births
0
1
2
3 or more
How much does menstruation and the surrounding period usually affect you?
I barely notice it at all; mild symptoms, easy to manage
Moderately difficult, but manageable
Significantly drains my energy
Severely affects me, difficult to function
Very severe symptoms, completely disrupt my routine
Have you ever been diagnosed with a hormonal condition? (for example: thyroid disorder, PCOS, insulin resistance, endometriosis)
Recent blood test results
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Lifestyle Habits – Daily Routine
Average daily water intake
*
Under 0.5 L
0.5–1 L
1–2 L
2–3 L
3–4 L
Over 5 L
Do you regularly consume caffeinated drinks?
*
No
Yes
Please describe what type of caffeinated drinks you consume and how much per day.
Do you currently smoke?
*
No
Occasionally
Yes, regularly
How long have you been smoking, and how much do you smoke daily or weekly?
How often do you consume alcohol?
*
Never or almost never
Rarely (a few times a year)
Occasionally (1–3 times a month)
Regularly (1–2 times a week)
Frequently (3–5 times a week)
Very frequently (daily or almost daily)
Have you ever used any mind-altering substances? (excluding alcohol, caffeine, and nicotine)
*
No
Yes, I currently use occasionally
Yes, I currently use regularly
Yes, I used to use, but not anymore
I prefer not to answer
What type of work schedule do you have?
*
Daytime
Night shift
Rotating shifts
Other
Average amount of sleep
*
5–6 hours
7–8 hours
9–10 hours
Other
How would you rate your stress level in general?
*
0 (no stress)
1–9
10 (constant, extreme stress)
Does stress affect your sleep or eating habits?
*
Yes, I have sleeping difficulties
Yes, it causes loss of appetite
Yes, it causes binge eating
I don’t feel that it affects me
Do you experience stress eating or binge eating due to tension?
*
Yes
No
Sometimes / in certain situations
Exercise and Activity
What is your general daily activity level outside of exercise?
*
Mostly sedentary work
Mixed (sitting + standing)
Mostly standing work
Physical labor / a lot of movement
I manage a household / spend all day with children
Other
On average, how often do you exercise per week?
*
Never or almost never
Rarely (1–2 times a month)
Occasionally (once a week)
Regularly (3–4 times a week)
Very regularly (4+ times a week)
Have you done sports before? If yes, what kind?
Goals
What is your goal?
*
Weight loss
Muscle gain
Maintenance
Other
What previous attempts have you made? What worked / what didn’t?
What motivates you the most to change your lifestyle?
*
I accept the privacy policy and consent to the processing of my personal and health-related data for the purpose of personalized nutrition counseling and lifestyle program planning.
*
Yes, I agree
Submit
Should be Empty: