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.
Strength
Endurance
Body Fat Change
Weight Loss
Weight Gain
Health Concerns
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
Yes (share if possible by email or link)
No
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
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
I did not gain weight
Pregnancy
Medication
Stopped Smoking
Lifestyle/Habits
Body Building
Other
Yes
No
Not sure
Yes
No
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.
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

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