HEALTH QUESTIONNAIRE
Please fill out the following form to get detailed information to setup the perfect nutrition plan.
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Email *
1. NAME *
2. AGE *
3. PHONE NUMBER *
4. WEIGHT / HEIGHT *
5. OCCUPATION *
6. EXERCISE FREQUENCY *
7. ANY MEDICATION TAKEN? *
If YES on question #7, please list and the intake frequency. If NO, please continue with next question. *
8. Do you drink alcohol?
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If YES on question #8, answer how many per day and how many days of the week. If NO, please continue with next question.
9. ANY ALLERGIES OR MEDICAL CONDITIONS? *
If YES on question #8, please list them. If NO, please continue with next question. *
10. HOW MANY MEALS DO YOU EAT DAILY? *
11. CAN YOU PLEASE MAKE A LIST OF YOUR DAILY HABITS? *
12. WHAT TIMES DO YOU TYPICALLY EAT BREAKFAST? WHAT ITEMS DOES IT INCLUDE? *
13. WHAT TIMES DO YOU TYPICALLY EAT LUNCH? WHAT ITEMS DOES IT INCLUDE? *
14. WHAT TIMES DO YOU TYPICALLY EAT DINNER? WHAT ITEMS DOES IT INCLUDE? *
15. WHAT TIME DO YOU TYPICALLY GO TO SLEEP? *
Time
:
16. WHAT TIME DO YOU TYPICALLY WAKE UP? *
Time
:
17. RATE YOUR SLEEP QUALITY *
Terrible
Great
18. WHAT ARE YOUR AVERAGE HOURS OF SLEEP *
19. DO YOU HAVE INTERRUPTIONS DURING  YOUR SLEEP? HOW MANY TIMES DOES IT HAPPEN? *
20. WHAT HAVE YOU TRIED FOR DIET AND EXERCISE IN THE PAST? *
21. WHAT ARE YOUR SHORT TERM GOALS IN 30 DAYS? 60 DAYS? 90 DAYS? *
22. WHAT ARE YOUR LONG TERM GOALS IN 9 MONTHS - 1 YEAR? *
23. RATE YOUR DESIRE TO ACCOMPLISH YOUR GOALS (1 LOW AND 5 HIGH) *
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