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NC Lifestyle Questionnaire
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* Indicates required question
Email
*
Your email
Name
Your answer
Surname
Your answer
Contact numbers
Your answer
Please indicate which of the programs you are interested in doing
Assessment
Exercise
Nutrition
Lifestyle
Custom
Birth date
MM
/
DD
/
YYYY
Height
Your answer
Weight
Your answer
Neck measurement in cm (narrowest point)
Your answer
Wrist measurement in cm (at fullest point)
Your answer
Forearm measurement (at fullest point)
Your answer
Bicep measurement (at fullest point)
Your answer
Waist measurement (at navel)
Your answer
Waist measurement (narrowest point)
Your answer
Hip measurement (at fullest point)
Your answer
Thigh measurement (at fullest point)
Your answer
Sleep Routine
How many hours do you sleep per night?
Most days
Some days
Every now and then
Certain times of the month
When stressed
Less than 4 hours
6 hours or less
7-8 Hours
8-9 hours
9 plus hours
Disturbed Sleep (waking 1-2 times a night)
Insomnia
Most days
Some days
Every now and then
Certain times of the month
When stressed
Less than 4 hours
6 hours or less
7-8 Hours
8-9 hours
9 plus hours
Disturbed Sleep (waking 1-2 times a night)
Insomnia
What time on average do you go to bed?
Your answer
What time on average do you wake up?
Your answer
Do you avoid alcohol and drugs?
Yes
No
Clear selection
Do you think you eat a healthy diet?
Your answer
What do you mainly drink every day
Water
Fruit juice
Sodas
Coffee
Tea
Alcohol
Toxic Burden
This section determines your toxic burden which could be having a significant impact on your current health.
Do you use natural/organic personal hygiene & beauty products?
Yes
No
Clear selection
Do you use natural/organic home cleaning products?
Yes
No
Clear selection
Where did you grow up ? (City, Rural or other please specify )
*
Your answer
Did you suffer from any particular illness or ailments as a child ? (Asthma, Allergies, infections etc)
*
Your answer
How were you born? - cesarean / natural
*
Your answer
Do you remember when your health changed? ( Specific event a gradual onset or always struggled)
*
Your answer
Social, Physical & Environmental
Do you usually feel that you can manage all of the tasks required of you in a given day?
Yes
No
Clear selection
Do you have family and friends ready to help and support you if needed?
Yes
No
Clear selection
Do you get at least thirty minutes of exercise or activity each day?
Yes
No
Clear selection
Do you get at least thirty minutes of sunshine and fresh air a day?
Yes
No
Clear selection
What is your present occupation?
Your answer
Does your occupation involve much physical exercise i.e. lifting,walking?
Your answer
Relationship status
Single
Married
Divorced
In a relationship
Clear selection
Do you have children?
Yes
No
Clear selection
Do you have any existing medical conditions (e.g diabetes, auto-immune diseases, heart conditions etc.) Please expand.
Your answer
Family health history - Father Mother did they suffer with any illness
*
Your answer
Do you use any medications? Please expand.
Your answer
Do you have any injuries that affect your current lifestyle.
Your answer
What operations have you had in the past?
Your answer
Do you have any mercury fillings?
Your answer
Do you suffer from any mental condition (e.g. depression etc.)
Your answer
What is your current mental state?
I'm optimistic about the future
I'm pessimistic about the future
I'm neutral about the future and take things at it comes
Other
Clear selection
What are your current stress levels on a scale of 1-10.
Relaxed and happy, not very stressed at all
1
2
3
4
5
6
7
8
9
10
Extremely stressed, affecting your mental & physical state
Clear selection
Have you experienced any of the following in the last year?
Death of a spouse
Divorce
Marital separation
Jail term
Death of close family member
Personal injury or illness
Marriage
Fired at work
Marital reconciliation
Retirement
Pregnancy
Change in financial state
How much did these events affect you
Slightly
1
2
3
4
5
Extremly
Clear selection
What religion are you? (This question helps us in considering and respecting your beliefs when offering certain advice)
Your answer
Please describe in short a typical day from waking up to bedtime.
Your answer
Why did you contact Nutricoach? What is the outcome you wish to achieve?
Your answer
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