Nutrition Questionnaire

First Name? Mary

Age?

Weight?

Height?

Male or Female (to put together the most medically accurate program for you)?

1. What does your support system look like? (helps me understand your day to day)

2. Are you taking any vitamins or supplements or medications? If so, please list why you are taking them. (medical reasons, could interact in your fitness or your nutrition)

3. How many meals do you typically get in a day? What do they look like? Example: 3 meals. 1. usually coffee and maybe a granola bar. 2. mcdonalds hamburger and a coke. 3. I'll cook something for dinner, last night was spaghetti with red sauce. ( so I don't create a program for you that is unrealistic )

4. Any dietary/medical restrictions or allergies? (so you don't turn into an angel early)

5. Do you drink coffee? If so, how do you drink it? Example: black coffee with 2 tbsp sugar and a lot of creamer. (a lot of my clients do, this could be the secret reason why that you are not finding success)

6. Do you drink soda or alcohol? Smoke? ( Soda, Alcohol and smoking all play a factor in health, this way I know how to keep my programs realistic for your success)

7. Any foods you hate or will not eat? (if I put a program together for you that has fish in it, and you hate fish, then I just wasted both our time)

8. Will you eat green vegetables? (to create a successful program for you)

9. Sweet or Salty tooth? If yes to either or both, then please list item(s). (finding a realistic healthy substitute is a life game changer!)

10. Favorite snack? Or item you will continue to eat no matter what. (so I can work it into your program ... seriously, I will)

11. Comfortable with drinking a premade protein drink? Or a protein powder? If so, what brand? (some people will, some will not even try, this why I know what's realistic)

12. If you work, what is your job? Is it active or inactive? When’s your day(s) off? Example: stay at home parent. Example: I am a bank teller. Sometimes active. Sat & Sun off. (hold you accountable and help you schedule)

13. How can I guarantee you success? (so I know my approach I need to take with your program(s))

14. What are your expectations out of these programs? (make sure we are "on the same page")

15. What is your Nutrition S.M.A.R.T. (Specific, Measurable, Attainable, Relevant & Timely) goal? (outlines what it takes to attain your desired wellness level)

Incorrect Example: get healthier

Correct Example: To get healthy by next year, I will eat more balanced meals and start exercising. I will exercise __times per week for at least __minutes. I can choose between weight lifting, running, and swimming. I will meal prep on ___day to make sure I eat enough healthy foods throughout the week.