Nutrition and Fitness Questionnaire


All about YOU:


1.   Have you ever received a nutritional or Fitness consultation?

     Yes No
If Yes please explain

2. Explain why you would like to receive Nutrition counseling at this time.
(select all those that apply by holding the control key while clicking)


3. What are your long term goals?  List three.

4.  What are your short term goals? List three.

 5.  Do you workout?  When?  How often?  How long?

Nutrition History

1.    What is your:

a. Current Weight

b. Height

c. Body composition

d. Date of birth


Your food intake for the day

Please type down a typical day of food intake.  Include water, juices, snacks, fruit, veggies, dairy, and meat and alcohol.


Are you currently taking any medications?  Please list. 


Please list injuries or conditions that may slow your progress


Realistically please list what you would like to accomplish in the next 8 weeks.


Enter any other comments in the space provided below:



Email:   [required]




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