Nutrition Plan Questionnaire Personal details Name(required) Email(required) Age(required) Height(required) Weight(required) Waist circumference(required) Hip circumference (around the glutes)(required) Shoulder circumference What do you need help with? E.g. Improve my general healthy – improve energy, brain function, improve labs, etc), lose fat or build muscle. Be as specific as possible.(required) What is your goal? E.g. I want to lose at least 30lbs and gain about 20lbs of muscle, get visible abs and look great in swimming trunks. Be as specific with your goal/s as possible. (required) Lifestyle Describe your job. How many hours approx. are you on your feet, do you sit in front of a computer, etc.(required) How intense is your job on a scale of 1 – 10 with 1 being not intense at all? Describe physical and/or mental energy requirements.(required) On a scale of 1 to 10, how much stress do you experience in your career?(required) On a scale of 1 to 10, how much stress do you experience in your personal life?(required) At what time do you usually go to bed and wake up? And roughly, how often do you wake up during the night? Would you say the quality of your sleep is great, good, not too bad or awful?(required) Do you have difficulty falling asleep?(required) Yes No Do you have an exercise regimen? Please describe as specifically as possible. Include the activities, days/times, intensity and duration/volume.(required) Are there any other notes about your lifestyle that you would like to share?(required) Health history Do you have high blood pressure?(required) Yes No I don't know Do you have high cholesterol?(required) Yes No I don't know Have you done a lipid panel? If yes, please provide the information (cholesterol, triglycerides, etc.).(required) Have you done a thyroid panel? If yes, please provide information.(required) Have you tested blood sugar and insulin sensitivity? If yes, please provide information.(required) Have you had a liver test? If yes, please provide information.(required) Do you experience blood sugar roller coasters? Symptoms include feeling tired, irritated, depressed, etc. If so, when? E.g. 1-2 hours after a meal, specifically in the morning, mid afternoon, etc. Do you have fat specifically around the midsection?(required) Yes No Do you experience hot flushed and bouts of anger? Yes, often Sometimes, when I've gone without food for too long No What is your heart rate? What is your temperature when you wake up? What is your temperature after your first meal? Are you often sweaty in general and especially when stressed (sweaty palm and pits)? How often do you urinate? Often with small volume A few times a day with normal volume without having to force myself Not very often and I tend to forget and can get bladder pains Do you experience muscle weakness, twitching and spasms and have low exercise tolerance? Yes, almost always No never What's the size of your pupils overall? Small (constricted) Normal Large (dilated) Are you very focused and tend to ruminate on negative things that happened in the past? Yes Sometimes No Do you have ADHD like tendencies? Yes No, I can focus for good periods of time Do you have asthma like symptoms or COPD? Yes No Can you go long periods (5 plus hours) without food?(required) Yes No Do you experience chronic inflammation, such as cystic acne, wounds that take forever to heal and are constantly inflamed, inflamed gums, etc.(required) Yes No Do you experience hair loss or hair thinning? What is the quality of your hair?(required) What is the quality of your nails? Do you have any white spots, vertical lines, etc?(required) Do you experience headaches/migraines?(required) Very frequenctly Sometimes Almost never Do you have any visual issues (e.g. blurry vision, myopia, etc.)?(required) Do you have skin issues, such as psoriasis, rosacea , dandruff, etc? (required) Do you have a white coating on your tongue? Yes, on most of my tongue Yes, but only at the back No, not at all Do you have nasal congestion? Yes, quite often Sometimes, but usually only after eating certain foods No, rarely ever How often do you get cold sores on your lips and/or tongue? How often do you get sick (e.g. cold, fever, etc.)? How are your bowel movements?(required) Generally constipated Most often diarrhea A combination of both Generally slow and tarry Pretty good bowel movements – solid, no pain, smooth delivery, and no dirty wipe. Do you experience stiff, swollen or painful joints?(required) Sometimes Often No Do you have water retention on your ankles? Yes No Does your mouth produce a lot of saliva? Yes, I have to swallow a lot when I talk No, I have a rather dry mouth Normal – not too much, not too little How do you feel emotionally? More emotional than others and I tend to cry often My emotions are normal I have anhedonia Do you have anxiety in your day to day life? Yes, a lot Somewhat, but mostly only in a social setting Rarely Not at all Do you experience cold hands or feet?(required) Sometimes Often No Are you currently taking any medications, excluding nutritional supplements?(required) Yes No If yes, please be specific about the medication you are currently using. Do you smoke?(required) Yes No Do you have any medical issues that I should be aware of? Anything you currently have or have been treated for in the past? E.g. asthma, diabetes, heart disease etc. If yes, please elaborate.(required) Please list any known food intolerance or sensitivities you have.(required) Nutrition Regarding health and nutrition, what methods/advise have you tried before that have not worked for you? Please elaborate and be as specific as possible about why it didn't work for you.(required) What methods/advice have you tried that have worked for you?(required) Do you count or track calories?(required) Yes No Do you have time available to prepare your own food each day? (required) Yes No If you don't have time to prepare every meal, be specific about which meals you do have time to prepare(required) Breakfast Lunch Dinner Do you have time at night to prepare food for the following day?(required) Yes No Would you enjoy fruit smoothies for any meal or snack of the day? (It's very time effective)(required) Yes No Do you eat breakfast? If yes, what does a typical breakfast look like? Don't forget to include approx. size and/or approx. measurements:(required) What does a typical lunch look like for you?(required) What does a typical dinner look like for you?(required) Do you snack during the day? If yes, on what do you normally snack? How often do you snack and how much of it do you consume at a time?(required) Do you constantly look forward to the next meal, frequently think about food and what you want to eat for your next meal?(required) Yes, most of the time No, rarely What is your appetite like at breakfast?(required) a) Non exist b) Somewhat, but I can get away with a coffee until about 10/11am c) I usually wake up hungry and have to eat something What is your appetite like at lunch?(required) a) Non existent. I usually skip lunch b) Somewhat but I can get away with a snack c) Usually always hungry with a good appetite What is your appetite like at dinner?(required) a) Non existent b) Somewhat but I often skip it if I had a big lunch or snack for linner (after lunch and dinner) c) Usually always hungry with a big appetite After which meal do you normally feel tired/drowsy?(required) Breakfast Lunch Dinner Every meal/snack I don't get tired after a meal, instead I usually feel energized Do you experience heartburn, bloating, burping, intestinal gurgling, constipation, diarrhea, pains or cramps after eating certain foods? Have you identified any trigger foods? Please list the offensive food as well as the symptoms you experience from that food in brackets: E.g. cabbage (painful bloating & flatulence), rice (appendix pains)(required) Carbs Does a high carb meal with lots of veggies, bread, cereals, rice, fruits, grains or potatoes as the main food source, satisfy your appetite or stimulate your appetite (make you feel hungry afterwards)?(required) 1 – doesn't satisfy my hunger and I feel quite hungry soon after the meal 2 3 4 5 – satisfies me completely and gives me energy for many hours afterwards Does a high carb dinner, such as potatoes, rice, fruit, honey, etc., make you sleep better or worse?(required) Better Worse Don't know. Haven't taken note of it yet Do you like beans and do you do well on them? If yes, please specify what type of beans you like and are available for you to buy. (required) Vegetables Please list all the vegetables you like (including tubers).(required) Please list all the vegetables you dislike and don't want to eat and also the ones you don't do well on.(required) Do you eat and enjoy beans? (required) Yes No Only now and then Fruit Do you like fruit?(required) Yes, but I don't crave it everyday No One or two fruit a day is enough for me I'm a fruit fly and love snacking on fruit in between meals or even having a fruit salad as a meal Do you like to snack on dried fruit and/or nuts? If yes, please specify what kinds of dried fruit and/or nuts you like. (if you are allergic to nuts then only list the dried fruit you like, if any) Please list all the types of fruit that you like and will have available for you to buy in the Summer.(required) Please list all the fruit that you like and will have available for you to buy in the Fall.(required) Please list all the fruit that you like and will have available for you to buy in the Winter.(required) Please list all the fruit that you like and will have available for you to buy in the Spring.(required) Please list the types of fruit that you definitely don't like and/or don't do well on.(required) Grains Please select the following grains that you tolerate well.(required) Oats Rice Sourdough bread Quinoa Millet Buckwheat None of the above Dairy Do you like milk and do well on it?(required) Yes No. I prefer other alternatives to milk I like milk but don't do well on it If you experience any negative effects/symptoms from milk, please list them. If you prefer other alternatives to milk, please list them here. Do you like cheese and do well on it?(required) Yes No, not at all Only low or no-fat cheese If you only prefer certain kinds of cheese, please list them.(required) Oils/fats What kind of oils and/or fats do you use for cooking, baking and frying?(required) Please check the box/es of the fats and/or oils that you do like and would prepare your food with.(required) Butter Ghee Virgin olive oil Coconut oil Tallow Macadamia nut oil Olive oil/coconut oil cooking spray Meat Do you digest red or white meat the best?(required) Red meat White meat Do you have a problem digesting meat in general (white and red)?(required) Yes No Only when I'm stressed Do you feel light or heavy after eating lean (not fatty), red meat, such as sirloin, top loin etc.?(required) Light Heavy Do you feel light or heavy aster eating fatty, red meat, such as T-bone steak, rib eye etc.?(required) Light Heavy Do you prefer chicken breast or chicken thigh?(required) Chicken breast Chicken thigh Would you say your productivity level is better when have white or red meat for lunch?(required) White meat Red meat Is your productivity level better when you have fatty or lean meat for lunch?(required) Fatty Lean Do you like/would be willing to eat seafood such as oysters, shrimp etc? Yes No List all the types of meat that you like and enjoy eating.(required) Do foods high in protein and/or fats such as dark meats, avocados, cream, butter, nuts and chocolate/cocoa within 1-2 hours of bedtime help you sleep better? If yes, please specify.(required) Cravings How often do you typically feel the need to eat on an average day? This includes meals as well as snacks, drinks, etc.(required) Do you enjoy and sometimes crave sour food such as green apples, pickles, pickled beets, olives etc.? If yes, please specify.(required) Do you enjoy and sometimes crave hot foods such as dishes with chili or curry etc.? If yes, please specify.(required) Would you rather eat something salty or something sweet?(required) Please give examples of what you crave as well as when you crave it. E.g. I crave a glass of hot chocolate milk before bed or I crave salty peanut butter after breakfast.(required) Workout nutrition Describe your pre-workout nutritional and/or supplemental habits, if any.(required) Describe your “during the workout” nutritional and/supplemental habits, if any.(required) Describe your post-workout nutritional and/or supplemental habits, if any.(required) List all nutritional supplements you are currently using. Include multi-vitamins, sport supplements, electrolytes, and any special juices, pills, capsules or tablets.(required) Liquids How much water do you drink per day, apart from exercise?(required) How much liquid do you consume per day, apart from water? Please be specific about the variety of liquids you consume.(required) Please describe any religious, ethical, or logistical limitations regarding nutrition.(required) Use the following section to include any additional nutritional notes. Final thoughts Describe what you truly desire from working with me. What do you truly desire? Out of your fitness? Out of life? What do you want your body to look like in 1 year? 5 years? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your specific goals or objectives? Be as honest and specific as possible, describing your dream body, lifestyle, or health. Pour yourself onto the page. Include anything that you feel would be helpful that you haven’t yet had a chance to express. All your responses remain completely confidential!(required) Submit Δ Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)MoreClick to share on LinkedIn (Opens in new window)Click to share on Reddit (Opens in new window)Click to share on Tumblr (Opens in new window)Click to share on WhatsApp (Opens in new window)Like this:Like Loading...