Nutrition QuestionnaireThank you for showing interest in nutrition coaching. Please fill out the form below so we can better serve you. Name * First Name Last Name Email * Height? Weight? Goals * Example: Sports specific, increase muscle mass, fat loss, improved performance, improved health and wellness, improved relationship with food. Rank in order of importance Most persistent nutrition related obstacle: Typical day of eating: Breakfast, Lunch, Dinner, and Snacks. Please add a brief description for each. How often do you grocery shop/have groceries delivered? 1-2 times a week 1-2 times a month How many times per week do you eat at restaurants or get take out? 0 1 2 3+ Do you currently prepare any food ahead of time? Yes No If you looked at a food, would you know if it consisted primarily or carbs, fats, or proteins? Yes to all No to all Yes to 2 Yes to 1 How often do you consume alcohol? Zero, no alcohol 1-2 times a week 1-2 times a month More than 4x week Have you ever tracked your food? Whether in a journal or app Yes No Dietary Restrictions/Allergies? How often do you workout? 1-2 times a week 4+ times a week No Exercise What style of working out do you do on a weekly basis? examples: spin class, running, weightlifting, etc.. Occupational Activity level Occupational Travel Do you travel for work; sales, clients, etc.. Yes No How many hours of sleep do you average per night? <6 hours 6-8 Hours >8 Hours What is the quality of your sleep like on a scale of 1(terrible)-10(best ever) Thank you!
