Custom Diet Plan Form – Women Health & Diet

Fill Questionnaire please

First Name

Last Name

Age

Gender

Email

Phone No.

What are your Fitness & Nutrition goals? For example flat tummy, tone body, lose weight, gain weight, Bigger Butt etc. Be as descriptive as possible

What is keeping you from achieving your Fitness & Nutrition goals? (Check all that apply)

Lack of Motivation Not enough Equipment Not enough of Time Lack of Results Hitting a Plateau Self Conscious Not Knowing Where or How to Start Other

What motivates you? (Check all that apply)

Seeing Results Having Fun Praise/Rewards Feeling Better Other

Do you follow a current exercise regime? Yes No If yes, please explain.

Are there any physical aspect that limit your participation in exercise?

Are you currently employed? If so, what type of physical activity do you do at work? Heavy lifting sitting, etc..

What activities/exercises do you currently participate in? (Check all that apply)

Running/Walking Aerobics Strength Circuit Biking Dance Free Weights Swimming Yoga/Pilates Martial Arts Sports Others

Tobacco Use:

I currently smoke I quit smoking < 6 months ago I quit smoking over 6 months ago I never used tobacco

Alcohol Use:

I frequently drink alcohol I occasionally drink alcohol I seldom drink alcohol I never drink alcohol

What is your current activity level?

None Little (Less than one hour a week) Moderate (1-5 hours a week) High (Over 5 hrs. a week)

Do you have any food allergies? Yes/No

How often do you eat out?

Almost Every day Once a Week Once a Month A Few Times a Week A Few Times a Month Rarely or Never

Prepare a 3-Day food journal

On average how much sleep do you usually get every night?

How would you describe your current diet? (Vegetarian, Vegan, Paleo etc...)

How much time do you spend sitting or being sedentary during the day?

Do you have any exercise preferences or specific activities you enjoy?

How would you describe your health?

Are you taking any prescription or over-the-counter medications or dietary herbs or any vitamins, minerals, or supplements? Yes/No

Do you have or has your doctor or another licensed healthcare professional told you that you have any of the following conditions?

Allergies Amenorrhea or absence of menstrual period >3 months Anemia Anxiety Arthritis Asthma Cancer Cardiovascular disease Celiac disease Chronic sinus condition Cigarette smoker Crohn’s disease Depression Diabetes Disordered eating Intestinal problems Gastroesophageal reflux disease (GERD) High blood pressure/ hypertension Hyper/hypo-thyroidism Hypoglycemia Insomnia Intestinal problems Irritable bowel syndrome Osteoporosis Polycystic ovary disease Currently pregnant or <3 months postpartum Surgeries or hospitalization Past injuries

Describe any other health conditions you have, or for which you take medication?

What would you like to do regarding your weight?

Lose Maintain Gain

What is your current weight?

What is your height?

Is there any other information that you think I should know?

Are there any foods that cause you digestive issues?

What foods you will not or would prefer not to eat?

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