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