nutrition coaching questionnaire

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This questionnaire is part of a comprehensive nutrition and lifestyle assessment by a Registered Dietitian (your Nutrition Coach). This assessment is not for the purpose of diagnosing any medical condition and is not a substitute for regular communication with your physician. The information gathered in this assessment will be used to design your personalized nutrition plan. I maintain high standards of confidentiality and your information will only be used to prepare your plan. If you have read and agree with the preceding statements, begin the questionnaire. If you have questions regarding the preceding statements, click here to send a note to Jan Dowell, Nutrition Coach.

Please reply so this information can be considered in preparing your Plan.

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country

Home Phone

When is your birthday? (Day/Month/Year)

Type of Plan Purchased*
Type of Plan Purchased*

Interested in nutrition coaching in pursuit of (check all that apply):*
Interested in nutrition coaching in pursuit of (check all that apply):*

	Strength
	Endurance
	Body Fat Change
	Weight Loss
	Weight Gain
	Health Concerns

Name and date of event you are training for (if applicable):

Events or Training Programs you have completed in the last year (if applicable):

What do you do when you are not training for health or performance? (Check all that apply)*
What do you do when you are not training for health or performance? (Check all that apply)*

	Work full time
	Work part time
	Volunteer
	Travel often
	Full time student
	Part time student
	Family obligations
	Religious activities
	Hobbies related to fitness
	Hobbies related to food
	Hobbies not related to food/fitness
	Other

Current or anticipated workout schedule (frequency, length of time, pace/intensity, weights):*
Current or anticipated workout schedule (frequency, length of time, pace/intensity, weights):*

Do you have a training schedule related to your goals?*
Do you have a training schedule related to your goals?*

	Yes (share if possible by email or link)
	No

Nutrition Coaching Areas of Interest (check all that apply):*
Nutrition Coaching Areas of Interest (check all that apply):*

	Fuel/Energy Level
	Healthier Food Choices
	Hydration/Muscle Cramping
	Meal Timing for Training and Competition
	Sports Injury/Rehab/Recovery
	Stomach troubles associated with fitness
	Supplements
	Weight Gain Desired
	Weight Loss Desired
	Other

How tall are you? If you haven't measured recently, go measure now!

How much do you weigh in the morning (after voiding)?*
How much do you weigh in the morning (after voiding)?*

Body Fat Percentage:

How was your body fat tested?*
How was your body fat tested?*

Resting Metabolic Rate (in calories):

How was your Resting Metabolic Rate tested?*
How was your Resting Metabolic Rate tested?*

VO2Max (if tested)*
VO2Max (if tested)*

Resting Pulse Rate (after sleeping, before rising count pusle for 60 seconds)*
Resting Pulse Rate (after sleeping, before rising count pusle for 60 seconds)*

Which of the following statements best describes you?*
Which of the following statements best describes you?*

If you lost weight in the last year, how much did you lose?*
If you lost weight in the last year, how much did you lose?*

Which method(s) did you use to lose weight? (Check all that apply)*
Which method(s) did you use to lose weight? (Check all that apply)*

	I did not lose weight
	Diet from a book or the internet
	Diet made up by myself
	Diet from a Registered Dietitian
	Diet program (Weight Watchers, Seattle Sutton, etc.)
	Worked Out More
	Weight Loss Medication
	Hypnosis/Acupuncture
	Lap Band Procedure
	Gastric Bypass Surgery
	Illness
	Other

If you gained weight in the last year, how much did you gain?*
If you gained weight in the last year, how much did you gain?*

To what do you attribute your weight gain?*
To what do you attribute your weight gain?*

	I did not gain weight
	Pregnancy
	Medication
	Stopped Smoking
	Lifestyle/Habits
	Body Building
	Other

Have you ever been treated for an eating disorder?*
Have you ever been treated for an eating disorder?*

	Yes
	No
	Not sure

Are you currently in treatment for an eating disorder?*
Are you currently in treatment for an eating disorder?*

	Yes
	No

How many times a day do you eat or drink something?*
How many times a day do you eat or drink something?*

Check any of these statements that describe you:*
Check any of these statements that describe you:*

	I can cook and I do cook.
	I prefer eating out due to convenience/travel.
	I live to eat.
	I eat to live.
	In the past I have journaled (kept a record) my food intake or workouts on a consistent basis.
	I am a good sleeper.
	Stress has negative impact on my food or fitness habits.
	I usually only eat when hungry and stop when I am getting full.
	I smoke.

List any prescription medications you take on a regular basis.*
List any prescription medications you take on a regular basis.*

List any over the counter medications you take on a regular basis.*
List any over the counter medications you take on a regular basis.*

List any nutritional supplements (powders, pills, potions) you take on a regular basis. If known, provide the brand and how much you take daily.*
List any nutritional supplements (powders, pills, potions) you take on a regular basis. If known, provide the brand and how much you take daily.*

List any herbal supplements you take on a regular basis.*
List any herbal supplements you take on a regular basis.*

Check all current medical conditions (to be considered in your personalized nutrition plan):*
Check all current medical conditions (to be considered in your personalized nutrition plan):*

	Asthma
	Alcohol or Drug Addiction
	Arthritis
	Cancer
	Crohn’s Disease
	Dehydration
	Depression
	Food Allergies
	Gluten Intolerance
	High Blood Pressure
	High Cholesterol
	High Triglycerides
	Iron-deficiency Anemia
	Irregular Menstrual Cycles
	Irritable Bowel
	Lactose Intolerance
	Migraines
	Osteopenia/Osteoporosis
	Physical Disability
	Polycystic Ovary (Ovarian) Syndrome (PCOS)
	Pregnancy (current or within last year)
	Stress Fractures/Broken Bones
	Type I Diabetes
	Type 2 Diabetes
	Vegetarian
	Other

List any food allergies (if applicable):

List any foods/beverages that you will not eat/drink:*
List any foods/beverages that you will not eat/drink:*

Type any additional information that you think your nutrition coach would like to know about your food, fitness, or lifestyle. If you have a concern that you want to be considered in your Plan, this is a great time to fill in the gaps of the questionnaire!

Please enter the word that you see below.