Nutrition Questionnaire
Please use this questionnaire if you are starting NUTRITION coaching.  If you are a fitness client or getting started, please go back to www.liftandlivefitness.com and select the "Health and Fitness Questionnaire" from the "Get Started" navigation.  

When you complete this questionnaire, please allow 15 minutes.  The better job you do answering the questions with complete information, the better job we can do coaching you to your goals!  Thank you!
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Email *
Client Name:
What is your ultimate (long term) goal related to nutrition?   *
What is your primary goal that you'd like to accomplish in the next 3 months with nutrition coaching? *
Are you currently following a specific meal / diet plan?  
Please describe a typical day's eating, including meals and snack times, foods, and portions *
Are you currently taking any supplements?
Are you currently taking any medications - including birth control, treatment for physical or psychological conditions? *
Do you smoke - cigarettes or marijuana? *
Do you know how many Calories you eat on a daily basis?  If yes, how many? *
Do you know how many grams of protein you eat on a daily basis?  If yes, how many grams?
 *
Do you know how much water you drink on a daily basis?  If yes, how many ounces? *
How would you rate your current diet? *
Poor
Excellent
Are you currently experiencing any of the following conditions? *
Required
Have you previously experienced any of the above conditions?  If yes, please elaborate. *
How is your energy through out the day?  Do you feel low energy at any point in the day? *
How is your appetite?  Strong, weak, average? *
Do you experience cravings?  If yes, WHEN do you typically experience cravings?  Do you typically crave salty or sweet? *
How is your mental state when you eat?  Do you ever feel stressed or bad about certain food choices? *
What purposes to you feel food serves in your life? *
Required
Out of 7 days in a week, how many days do you skip breakfast / do not eat within 2 hours of waking?
Clear selection
Please rate how much you enjoy eating the following foods *
Actively Dislike
Somewhat Dislike
Neutral
Somewhat Enjoy
Very Much Enjoy
Vegetables
Fruits
Nuts & Seeds
Legumes (including beans)
Whole grains
Are there any foods you strongly dislike / will not eat?  Please also specific foods to which you have reactions like bloating or allergies.  
Have you ever tracked Calories?  How do you feel about tracking?
Have you every meal prepped?  How do you feel about meal prepping?  
Do you intentionally eat before or after a workout? *
How many servings of Caloric beverages do you consume weekly, including soda, sweetened tea, flavored coffee drinks?
Are there any foods / drinks that you WILL NOT CONSUME?  Perhaps that you are allergic to?  Or have an aversion to?
Are there any foods / drinks that you absolutely LOVE and don't want to give up?  
Is there any additional information you'd like to me know / think I should know as we begin working together?   *
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