Nutritional Coaching Client Questionnaire

The questionnaire below contains some personal questions. These questions will give me an insight to you daily habits and help build a nutritional plan around these behaviours.

Please answer the following questions as honestly as possible, this will really help. The more information you can provide the better, feel free to provide me with as much information as possible in the notes section at the end of the questionnaire.

Name *

First

Last

Age *

Date of Birth *

What are your goals?

Improved health
Fat loss
Increased strength
Increased muscle mass
Weight gain
Be an example to people close to you
Learn to eat better
Sport specific*
Something else, explain below**

*Please provide the sport or event for which you are training:

**What is your goal?

Are you willing to make sacrifices with your time, your social life, and even your sleep to reach that goal? *

Yes
No
Maybe

Do you have a timeline for achieving that goal? If so, please specify: *

What do you see being the biggest challenges for you to accomplish your goal? *

Consistent Exercise
Diet
Time Management
Meal Planning
Checking in Daily
Support from family, friends, coworkers
Staying focused on weekends
Nothing, I'm ready to go!
Other*

*Other

Additional Comments or Concerns pertaining to your goal(s): *

What is your current workout routine? (including duration, frequency and intensity) *

Do you have any physical limitations? (asthma, bad knees, bad wrists, etc) *

What are your most and least favorite workouts?: *

If you have any diagnosed health problems, list condition(s): *

Please list any medications that you are currently taking: *

Any additional health information:

What do you do for a living? *

What is the activity level at your job? *

None (seated work only)
Moderate (light activity such as walking)
High (heavy labor, very active)

Does your job involve shift work? *

If you have a more regular schedule, do you work days, afternoons, or nights? *

Do you travel for your work? If so how often? *

Do you commute to and from your job? If so how long is your commute? *

Do you take any nutritional supplements? *

If yes, what supplements and what dosage?

Do you have any dietary restrictions? *

How many times a week do you eat out at restaurants? *

Have you ever tracked your calories? *

If you answered yes, do you feel it helped you with your weight loss goals?

Is there any other information that you feel I should know about your health, your eating habits, your exercise habits, food sensitivites, etc.?