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*
Last Name*
E-Mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country
Home Phone
When is your birthday? (Day/Month/Year)
Type of Plan Purchased*
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)*
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):*
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):*
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)?*
Body Fat Percentage:
How was your body fat tested?*
Resting Metabolic Rate (in calories):
How was your Resting Metabolic Rate tested?*
VO2Max (if tested)*
Resting Pulse Rate (after sleeping, before rising count pusle for 60 seconds)*
Which of the following statements best describes you?*
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)*
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?*
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?*
Yes
No
Not sure
Are you currently in treatment for an eating disorder?*
Yes
No
How many times a day do you eat or drink something?*
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 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 herbal supplements you take on a regular basis.*
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:*
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.