Health and Nutrition Questionnaire
Please take the time to answer every question carefully. Failure to answer any of the questions may affect the overall results of my advice.
Please inform me of your ethnicity (this is optional but may affect my recommendations)
Are you currently
Do you have children who depend on your cooking?
Do you suffer from or have you ever suffered from
Are you currently taking any medications?
If you answered YES, please list below (name, dosage, for what, how long)
Mild Activity (walking, taking the stairs)
Occasional Exercise (Less than 3x per week)
Regular Exercise (More than 3x per week)
Please list the types of exercise you participate in (i.e. yoga, running, weight training, spinning etc.)
How many hours of sleep do you get on an average night?
Less than 5 hours
How would you rate your daily stress levels?
None of the above
Please list below if you have any known food allergies or sensitivities
Are there any foods you do not eat by choice?
Do you drink alcohol
Yes, on occasion
Have you ever followed a diet?
If YES, please list below the diets you have previously followed
Were you successful with any of the diets?
If NO, please explain why not
Are you currently following a diet?
If YES, which one?
If YES, would you be willing to stop/change it should I recommend so?
When following a diet, where would you place the following statements?
I struggle to resist temptation
I struggle to find food alternatives
I struggle saying 'no' to myself
I struggle with emotional eating
I struggle with binge eating
I struggle with boredom snacking
I struggle to stay motivated
I struggle with social settings
I struggle with recipe ideas
Please write any other things you may be struggling with that are not listed above...
Is there any information you would like to add that is not mentioned in this questionnaire?
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