Custom Diet Plan Form

Fill Questionnaire please

1-First Name

2- Last Name

3- Gender

4-Age

5- Phone Number. Please include your area code

6- Email

7- Confirm Email

8- What is your current weight?

9- What is your height?

10- What are your fitness and nutrition goals? For example, are they to have a flat tummy, toned body, lose weight, gain weight, bigger buttocks, etc. Be as descriptive as possible.

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

13- Do you follow a current exercise regime? If yes, please explain.

No Yes

14- Are there any physical aspect that limit your participation in exercise? If yes, please explain.

No Yes

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

No Yes

17- Tobacco Use:

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

18- Alcohol Use:

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

19- 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)

20- Do you have any food allergies? If yes, please explain

No Not that I know Yes

22- Prepare a three day food journal. Basically let us know everything you ate the past three days.

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

4 hours or less 5 to 6 hours 7 to 9 hours More than 9 hours

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

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

1 to 6 hours 7 to 12 hours 13 to 18 hours 19 to 24 hours

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

27- How would you describe your health?

Poor Fair Good Excellent

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

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

31- What would you like to do regarding your weight?

Lose Maintain Gain

32- Is there any other information that you think I should know? If yes, please explain.

No Yes

33- Are there any foods that cause you digestive issues? If yes, please explain.

No Yes

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

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