NUTRITION AND LIFESTYLE QUESTIONARRE:

DIRECTIONS: Please take a few minutes to fill out this questionnaire for further nutritional/health evaluation.

General Nutrition Information

In general, how would you rate your daily nutrition and diet?

 Outstanding Good Have some concerns Poor

How many times do you exercise per week on average?

 Never 1-2 times per week 3-5 times a week

 Everyday 5-6 times a week

How often do you go out to eat per week? (Each meal counts as 1 time)

 1 or less 2-5 times More than 6

Nutrition Information

I eat a balanced diet and watch my caloric intake by maintaining an appropriate level of fats, carbs, and proteins:

 Yes I count all my macronutrients and only supplement vitamins/minerals if needed No

How many meals do you consume per day?Describe in detail below.

6 to 7 small meals a day depending on my training and fitness goals. I try and maintain a 50/30/20 carb/protein/fat ratio for my macronutrients. All carbs consist of whole grains and fibrous veggies and proteins/ fats come from lean sources of meat and poultry.

Check all of the following protein food sources that you typically like to consume. If checked, describe what type in further detail:

 Chicken  Legumes

 Turkey

 Dairy

 Beef

 Pork

Nuts

I consume white chicken mainly boneless skinless chicken breasts along with a serving of lean ground turkey or lean ground beef every other day. I do not consume any beans or pork. I receive my other protein sources from eggs which is the only dairy product I consume at this time.

How many servings of carbohydrates would you say you get in a day?

 1-5 servings |  5 plus servings

I find it difficult financially to be able to purchase unprocessed, organic food sources:

 Yes |  No

Do you consume tobacco products? If yes, describe:

 Yes Quit smoking 6 months ago and chew 4mg of nicotine gum when needed to avoid cravings |  No

Do you consume alcoholic beverages? If so, how many times per week?

N/A

Nutrition Information (continued)

Check the following carbohydrate sources that you typically consume, others not listed describe below:

 Pasta

 Whole grains (brown rice, wheat bread)

Rice (white)

 Green Vegetables

White Potatoes

 Legumes (Beans, Sprouts, etc)

Berry Fruits (strawberries, blueberries)

Melon Fruits (watermelon, cantaloupe, pairs)

Other vegetables

Describe your weekly exercise regimen in detail if applicable::

Anaerobic weight training 4 times a week supplemented with 45 minutes of low intensity aerobic cardio 6 days a week split between 30 minutes of fasted morning cardio, then post workout 15 minutes of low intensity cardio with sprint intervals every 30 seconds.

Nutrition Information (Continued)

I get at least 25g of fiber a day:

 Yes |  No

Check the following phrases that relate to you:

 “I would really like to lose weight, but I just don’t have the time.”

 “I have been exercising and following a strict diet, but still can’t seem to lose weight”

“I would like to start dieting due to my health concerns”

 “I can’t afford to eat healthy”

 “I just don’t like to exercise”

 “Having a disability makes it hard to eat healthy and workout”

“I want to live healthy, just don’t know where to begin”

“I am content with my health and nutrition, but would like to maximize my health and wellness potential”

List your Age, Height, and Weight in the space below:

6’1 170pounds 26 years old

Additional Information:

Please list any other dietaryand lifestyle concerns not listed within this questionnaire including medication, disabilities, and food allergies.

N/A

Mike BortnowskiBasic NutritionNutrition and Lifestyle Questionnaire—6/13/14