Nutrition Plan Design Questionnaire

Contact Details

Name*

First Last

Age*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date (please input date as mm/dd/yyyy)*

Lifestyle

Describe your job.*

Do you consider your job physically challenging or active?*

How many hours per day do you spend in front of a computer?*

On a scale of 1 to 10 (1 = no stress, 10 = a lot of stress), please rate the amount of stress in your career.*

On a scale of 1 to 10 (1 = no stress, 10 = a lot of stress), please rate the amount of stress in your personal life.*

What time do you usually go to bed at night and wake up in the morning?*

Are there any other notes about your lifestyle that you would like to share?*

Health History

If you answer "yes" to any of these questions, please provide details such as date of occurrence, frequency, intensity, amount, etc.

What is your age?*

What is your height?*

What is your weight?*

Do you suffer from back pain?*

Yes
No

If yes, please give details.

Are you sensitive to touch/pressure in any area?*

Yes
No

If yes, please give details.

Do you have tension, numbness or pain in a specific area?*

Yes
No

If yes, please give details.

Do you experience frequent headaches?*

Yes
No

If yes, please give details.

Are you pregnant?*

Yes
No

If yes, please give details.

Have you ever given birth?*

Yes
No

If yes, please give details.

Do you have high blood pressure?*

Yes
No

If yes, please give details.

Do you have high cholesterol?*

Yes
No

If yes, please give details.

Have you ever had surgery?*

Yes
No

If yes, please give details.

Have you ever broken any bones?*

Yes
No

If yes, please give details.

Do you experience stiff, swollen or painful joints?*

Yes
No

If yes, please give details.

Do you have difficulty sleeping?*

Yes
No

If yes, please give details.

Do you experience fatigue or lack of energy?*

Yes
No

If yes, please give details.

Do you experience cold hands or feet?*

Yes
No

If yes, please give details.

Have you ever been advised by a physician to avoid any type of exercise?*

Yes
No

If yes, please give details.

Have you ever been knocked unconscious or suffered a concussion?*

Yes
No

If yes, please give details.

Do you or does someone in your family have a cardiac condition?*

Yes
No
Third Choice

If yes, please give details.

Do you have any known alleries?*

Yes
No

If yes, please give details.

Are you currently taking any medications, not including nutritional supplements?*

Yes
No

If yes, please give details.

Do you smoke or have you smoked in the past?*

Yes
No

If yes, please give details.

Do you have any medical issues that have not yet been discussed in this questionnaire?*

Yes
No

If yes, please give details.

Nutrition & Metabolism

Have you ever had your metabolism tested?*

Yes
No

If yes, please give details.

Do you count or track calories?*

Yes
No

If yes, please give details.

Does a high carb snack or meal, with lots of veggies, bread, toast, cereals, rice, fruits, grains or potatoes as the main food source satisfy or stimulate your appetite?*

Do you notice that you gain a lot of weight when you eat red meat, or lose weight? Do you look slimmer in the mirror or do your clothes fit easier?*

Do you constantly look forward to the next meal, frequently thinking about foods and what you want to eat?*

What is your appetite like at breakfast?*

What is your appetite like at lunch?*

What is your appetite like at dinner?*

Do higher fat foods and/or higher protein foods such as dark meats, avocados, cream, butter, or coconuts within 1-2 hours of bedtime help you sleep better?*

If you ate a large salad with some low-fat meat like chicken breast for lunch (versus a higher fat meat like a hamburger patty), how would it affect your productivity the rest of the afternoon?*

What about if you ate a steak?*

How often do you typically feel the need to eat on an average day? One meal would be a 1, three meals a day would be a 5, while six to seven meals a day would be a 10.*

How much do you enjoy sour foods like pickles, sauerkraut, or vinegar?*

At Thanksgiving or a meal where you eat turkey, assuming all the turkey is moist, if you prefer white meat give yourself a 1, dark meat a 10, and no preference a 5.*

What is a typical breakfast?*

What is a typical lunch?*

What is a typical dinner?*

Describe your snacking habits in between breakfast, lunch, and dinner:*

Describe your pre-workout nutritional habits, if any:

Describe your “during the workout” nutritional habits, if any:

Describe your post-workout or nutritional habits, if any:

Describe all nutritional supplements you are currently using. Include multi-vitamins, sport supplements, electrolytes, and any special juices, pills, capsules or tablets:*

How much water do you drink per day, apart from exercise?*

How much water do you drink during exercise?*

Please describe any known food sensitivities, or intense likes/dislikes:*

Do you ever have heartburn, gastrointestinal distress, or stomach problems? If yes, please explain.*

Please describe any religious, ethical, or logistical limitations regarding nutrition (include information about any current nutritional sponsors):*

Use the following section to include any additional nutritional notes:

Final Thoughts

Your Goals

Describe what you truly desire from completing this program. What do you truly desire? Out of your fitness? Out of life? What do you want your body to look like in 1 year? 5 years? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your specific goals or objectives? Be as honest and specific as possible, describing your dream body, lifestyle, or health. Pour yourself onto the page. Include anything that you feel would be helpful that you haven’t yet had a chance to express. All your responses remain completely confidential!

Greenfield Fitness Systems

Performance, Fat Loss, Nutrition Solutions from Ben Greenfield

Contact Details

Lifestyle

Health History

Nutrition & Metabolism

Final Thoughts

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