Nutrition Questionnaire
Fill out the form carefully for registration
Client Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
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December
Month
Please select a day
1
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Day
Please select a year
2025
2024
2023
2022
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2020
2019
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1925
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1921
1920
Year
Gender
Please Select
Male
Female
N/A
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
Company
Diet
Please Select
vegan (eats no animal products/biproducts)
vegetarian (eats dairy and eggs)
pescatarian (etas fish)
Ovotarian (eats eggs)
Carnivore (eats only meat)
Flexitarian (eats everything)
Do you have any food allergies? If yes please explain.
Do you have any specific dietary requirements? If yes please explain.
Are you currently taking supplements? If yes please explain.
What are you top 5 favorite veggies?
What are your top 5 favorite cheat meals?
Do you drink coffee? how many cups/day? how do you take it?
How many alcoholic beverages do you drink a week?
What is your drink of choice?
How many sodas do you drink a week?
What is your favorite kind of dessert/candy?
How many times do you eat a day? Please explain.
Do you prepare you own meals? Please explain.
How many times a week do you eat at a sit down restaurant?
How many times a week do you grab fast food? From where?
How much water do you drink a day?
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