Nutrition Questionnaire

NUTRITION QUESTIONNAIRE

All information submitted isstrictly confidential. Please answer
the following questions to the best of your ability and be as specific as possible in order for me to serve you best.
Date: / ______/______/______

Day Month Year

Tell Us About Yourself
NAME ______EMAIL ______

PHONE (______) (______) AGE______HEIGHT ______

Weight (if you know) ______

Do you smoke? Yes No Do you drink? Yes No
if yes, how many typically in a day______Ifyes,how much at a time? ______

Do you sleep well? Yes No

What goals would you like to accomplish? Please check all that apply.

Lose Weight Decrease Body Fat Grocery Shopping Guide

Establish Healthy Eating Habits Reduce Portion Sizes Meal Plan
Maintain Weight Increase Energy Recipes

Stay Accountable Eat More Protein Track Food Intake

Increase Healthy FatsLearn About Healthy Carbs

Other ______

Are you interested in a specific diet? Yes No

If Yes, which one? ______

On a scale of 1 – 10, how would you rate your Nutrition?
(1 = very poor, 10 = excellent) ______

How many times a day do you usually eat (including snacks)? ______

What types of food do you usually eat? ______
______
______

Do you skip meals? Yes No Do you eat breakfast? Yes No

Do you eat late at night? Sometimes Often Never

What activities do you engage in while eating? (TV, Reading, Etc) ______
______

How many glasses of water do you consume daily? ______

Do you feel your energy levels drop throughout the day? Yes No

If yes when? ______

Do you know how many calories you eat per day? Yes No

If yes,how many? ______

If no, do you plan on tracking your food this way? ______

Besides Hunger, what other reason(s) do you eat?

Boredom Social Stressed Nervous Tired Depressed Happy

Do you eat past the point of fullness? Often Sometimes Never

List 3 specific areas of your nutrition you would like to improve first:
1 ______

2 ______

3 ______

Is anyone in your family overweight? Mother Father Sibling Grandparent

Were you overweight as a child? Yes No If yes, at what age(s) ______

If you could lose weight, how much would you like to lose? ______

Current Weight ______Goal Weight ______

Do you have a timeframe in mind? Please keep in mind a safe, effective weight loss ranges

From 1-2 lbs per week.
______

Are you currently exercising? Yes No Ifyes, what activities are you doing?

______
______
______

Please list 5 of your favourite foods
1 ______

2 ______

3 ______

4 ______
5 ______

Are there any foods you do not like? Yes No If yes, please list
______

______

______
______

Do you have any food allergies? Yes No If yes, please list
______

______

Do you have any health conditions that would affect yourdietary needs?
Yes No If yes, please explain
______

______

Do you crave any certain food? Yes No If yes, please list
______

______

Is there any other information you can provide in order for me to help you reach your goals?

______