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Questionnaire
Questionnaire
Fill out the form below to get started!
I will design a customized nutrition program that fits your lifestyle to ensure easy transition for a healthier diet.
During your first consultation with me, we will discuss your primary fitness Goals. And design a program for your needs.
Health & Nutrition Background
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Your Name
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Your Email
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Phone Number
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Height
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Weight
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Date of Birth (01/01/1980) Format
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Your goal (short term and long term) and/or reasons for wanting my services
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Detailed food log of what you eat on a typical day, for one weekday and one weekend day (Breakfast, lunch, dinner, snacks, beverages, times you ate, what, when, where, amount, even brands of foods are helpful)
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Favorite Foods
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Foods you dislike or have intolerance to: (i.e. Lactose)
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Any food allergies?
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List all medications and supplements
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Medical conditions or dietary restrictions
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Do you smoke or drink? How much, how frequently?
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Exercise routine (duration of exercise, how many days per week)
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What time do you go to bed? what time do you wake up? on average how many hours of sleep do you get?
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Occupation (how many days per week and how many hours)
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On average are you Sedentary, Moderately Active, or Highly Active, this does include your work if it is labor intensive
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Do you have access to fridge and microwave at work, do you get breaks in order to eat?
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Are than any times when you need to eat out (fast food/ or restaurants)? Where do you usually go?
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List any other information you think I need to know about or any questions you may have
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Do you like to cook?
