Nutrition Coaching Questionnaire
First Name
Last Name
Email
Phone
Current Weight
Goal Weight
Birthday
Height
Ultimate goal of your nutrition coaching is to:
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Select
Lose weight (scale lowers)
Gain muscle (may gain weight)
Athletic performance (results based on workout goals only)
What is your job title? Please describe your work tasks.
At your job, you're:
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Select
On your feet most of the day (nurse, mail carrier, etc).
At a desk most of the time (limited movement).
A little of both/ depends on the day.
Current exercise routine is:
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Select
Little to no activity
Mild (intense exercise 2-3x per week, at least 30 min each)
Moderate (intense exercise 4-5x per week, at least 1 hour each)
I have the following:
Checkbox Description
Air Fryer
Instant Pot
Crock Pot
At home:
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I'm in charge of cooking.
Someone else in my family cooks.
Trouble points, pertaining to eating:
Peer pressure
Night eating
Boredom eating
Alcohol
Unhealthy food choices
Lack of planning
Restaurant/Fast food
Not eating enough
Not sure what's considered healthy eating
I typically eat breakfast:
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Never
Within 30 min after waking
Within 1-2 hours after waking
Special circumstances:
Checkbox Description
Vegan
Vegetarian
Lactose Intolerant
Please list any foods you DO NOT eat.
Please list any supplements you take daily.
Have you ever had an eating disorder? (This is confidential)
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Select
No
Yes
Please list any allergies that are related to food.
Please list any current medications, and what they treat.
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