Questionnaire to receive personal information

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First Name *

Last Name *

Marriage status *

Pervious job *

Referred by *

Education *

Phone *

Gender *

Email *

Birthday *

Language *

Jobs *

General Questions

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Why are you here to see me? *

What have you tried in the past? *

What might hold you back? *

What kind of exercise do you do during week?

What are your goals? *

Why do you want to change? *

How motivated are you on a scale of ten? *

Physically activity *

Measurement

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Height *

Abdominal *

Hip *

Weight *

Waist *

Mood

Health

Nutritional status

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Do you drink coffee or tea? If yes, how much per day *

Please list another drink you consume?

How many times a week do you eat meat? *

How many fruits do you eat a day? What is your favorite *

What foods do you not like? *

Do you like fast food? *

Does stress or anything else make you eat too much or too little? *

Do you think you chew enough food in your mouth when you eat? *

How much water do you drink daily? *

Do you drink alcohol? If yes, how often and how much *

How many vegetables do you eat daily? *

What are your favorite foods? *

How many times a week do you go to a restaurant? *

How many times a month do you go to parties? *

Do you like snacks? If yes, what kind *

Do you experience problems after meals? *

Three Days Meals

Please list everything you eat and drink for three days, including food, drinks, medicine, and vitamins... in detail, along with the amount and time of consumption.

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First Day *

Second Day *

Third Day *

Disclaimer

You have confirmed that all the provided information is accurate to the best of your knowledge. You have agreed that we can relay your information with other health or fitness practitioners for the sole purpose of seeking better health, dietary, or fitness suggestions. You have confirmed that you are reaching us solely as a client and not patient. Further, you also understand that we cannot make any diagnosis or treatment plans for you; all information relayed on our behalf are suggestions to be approved by your doctors and/or health practitioners. You have understood that we are not liable for any of the suggested health products supplied by a 3rd party; you must do your own prior research before use. *

Agree

General Questions

Measurement

Mood

Health

Nutritional status

Three Days Meals

Please list everything you eat and drink for three days, including food, drinks, medicine, and vitamins... in detail, along with the amount and time of consumption.

Disclaimer

The choice is yours! To live a healthy life.

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Sources