Nutrition Questionnaire - Fit and Shredded

Full Name*

Age*

Date of Birth*

Height*

Weight*

Email*

Cell Phone Number*

Have you had blood tests? If yes, when was the last time? Were all the values good?*

Is your blood pressure normal?*

Is your digestive system working properly?*

Is your menstrual cycle regular?*

Are you taking any dietary supplements, vitamins, or medications in general?*

Do you suffer from any medically diagnosed condition?*

Weight history:

Have you gained or lost weight? If yes, do you know the reason? (psychological, hormonal, etc.)*

Have you been on diets before? If yes, what kind of diet did you follow?*

Dietary history: (24-hour recall - a typical day of your daily nutrition)

Breakfast: Mid-morning snack: Lunch: Afternoon snack: Dinner:*

Who cooks at home?*

Me
Spouse / Partner
Mother / Father
Mate
Other

Do you have favorite foods or preferences?*

Do you have any food aversions or allergies?*

Do you have any nutritional disorders? (Diabetes, hypoglycemia, etc.)*

Do you currently use a protein supplement/shake?*

Choose an Answer
Yes
No

Are you open to trying a protein shake?

Yes
No
Maybe

How often do you eat?*

6 or More Times a Day
3-4 Times a Day
Less Than 2 Times a Day
Whenever Hungry
Strickly Breakfast, Lunch and Dinner

How often, on average, do you eat any of the following foods? ● bacon ● burgers ● ground beef ● chicken wings ● pork products ● processed luncheon meats (ex. Ham, Salami, chicken) ● spare ribs*

Daily
3-4 Times a week
1-2 Times a week
3-4 Times a Month
1-2 Times a Month
Never

How often, on average, do you consume any of the following foods? ● cheeses (example; cheddar cheese, blue cheese, parmesan, cream cheese) ● homogenized milk ● yoghurt that is more than 1% milk fat ● ice cream*

Daily
3-4 Times a Week
1-2 Times a Week
3-4 Times a Month
1-2 Times a Month
Never

Do you use milk/cream in your coffee or tea?*

Yes
No

Fill in the amount of water you consume:*

0-1 per day
1-3 per week
3-5 per week
7 per week
Daily
None

What is your average soft drink consumption?*

3 or more drinks per day
1-2 drinks per day
2-6 drinks per week
Never

How often do you eat out?*

Almost Every Day
Less Than Once a Week
Less than Once a Month
Few Times a Week
Few Times a Month

Do you use regular sour cream or high fat salad dressings (example; Mayonnaise, French, Thousand Islands, Blue Cheese) more than once per week?*

Yes
No

How often do you eat fried foods?*

Daily
5-6 Times a Week
2-4 Times a Week
0-1 Times a Week

On average, how often do you consume of any of the following: wheat pasta, brown rice, beans, lentils, quinoa, peas, corn, barley, oatmeal?*

5 or More Days a Week
3-4 Times a Week
1-2 Times a Week
Never

How often, on average, do you consume any of the following foods? ● pastries such as cakes, croissants, coffee slices ● premium ice cream ● donuts ● biscuits (3 or more) ● high fat muffins ● rich desserts (ex. cheesecake, brownies, cookies)*

7 or More Times a Week
4-6 Times a Week
2-3 Times a Week
0-1 Times a Week

How often, on average, do you consume any of the following? ● nuts (almonds, walnuts, hazelnuts, pecans etc) ● seeds (pumpkin, sunflower, flaxseeds, chia, hemp, sesame etc.) ● legumes (alfalfa, peas, chickpeas, lentils, soybeans etc.)*

4-6 Times a Week
2-3 Times a Week
0-1 Times a Week

How often do you consume fruits per week?*

4-6 Times per Week
2-3 Times per Week
0-1 Time per Week

On average, how often do you consume garden type vegetables (ex. broccoli, kale, cauliflower, spinach, peas, carrots, tomatoes, peppers, romaine lettuce, collard greens)?*

Daily
4-6 Times a Week
2-3 Times a Week
0-1 Time a Week

How often, on average, do you consume any food or drinks that are highly processed and contain preservative, artificial flavours(● diet and regular soft drinks, sugary fruit drinks ● potato chips, pringles, nachos, cheesies etc. ● liquorice, gummy bears, jelly’s etc. ● ice cream, fruit ices, sherbet etc)*

3 or more per Day
1-2 Times a Day
2-3 Times per Week
Never or Once per Week

What is your average alcohol consumption?*

3 or more drinks per day
1-2 drinks per day
2-6 drinks per week
2-6 drinks per week
Never

Do you smoke?*

I Currently Smoke
I Quit Smoking Less Than 6 Months
I Quit Smoking More Than 6 Months
I Have Never Smoked

What is your current activity level?*

Sedentary (little or no exercise and a desk job)
Lightly Active (light exercise 1-3 hours a week)
Moderately (1-5 hours a week)
Very Active (heavy exercise 6-7 days per week)
Extremely Active (very heavy exercise or physical job or training twice per day)

What type of exercise are you currently doing?*

Cardio
Weight Training
Cardio & Weight Training
Yoga
Other
None

What goals would you like me to help you achieve in the next 90 days?*

Why are these your goals?*

Signature*

Health Questionaire

Weight history:

Dietary history: (24-hour recall - a typical day of your daily nutrition)

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