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EBM Fitness Solutions Nutrition Coaching Questionnaire.
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* Indicates required question
Name
Your answer
Contact information
Phone number, email or any way you prefer to be contacted.
Your answer
What are your goals?
Please check all that apply to you.
Lose weight/body fat
Gain muscle/add weight
Maintain weight
Improve physical fitness
Look better
Feel better
Have more energy
Get control of your eating habits
Improve athletic performance
If your goal was not listed, please list it below.
Your answer
Why are your goals important to you?
Your answer
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Your answer
Out of all of the above concerns, which ones feel most important/urgent? Include why they are the most urgent.
Your answer
Have you tried anything in the past to change your habits, your health, your eating, and / or your body? If so, what?
Your answer
Which of those things worked well for you? (Even if you might not be doing it right now.)
Your answer
Right now, how would you rank your overall eating/nutrition habits?
Horrible
1
2
3
4
5
6
7
8
9
10
Awesome
Clear selection
Why did you rank your habits the way you did?
Your answer
How long after you wake up do you wait until you eat something?
Although delicious, coffee is not food. This question is looking for how soon after waking you actually eat something.
Your answer
Do you currently use any supplements?
Could be vitamins, minerals, protein powder, bars, omega-3's or similar products.
Your answer
Do you have any digestive disorders?
*
This includes, but is not limited to: Celiac, Crohn's, lactose intolerance, reflux or ulcers.
Your answer
Who lives with you?
Spouse/partner
Roommate(s)
Child(ren)
Pet(s)
Other family members
Other:
Who does most of the grocery shopping in your household?
Your answer
Who does most of the cooking in your household?
Your answer
Right now, how much do the people and things around you support health, fitness, and/or behavior change?
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
On a scale from 1-10, how would you rank your overall health?
Terrible
1
2
3
4
5
6
7
8
9
10
Awesome
Clear selection
On a scale from 1-10, how do you feel about your schedule, time use, and overall busyness?
My life is panicked and stressed
1
2
3
4
5
6
7
8
9
10
My life is perfectly calm and relaxed
Clear selection
STRESS and RECOVERY
Given all the demands of your life, what is your typical stress level on an average day?
No stress
1
2
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5
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8
9
10
Extreme stress
Clear selection
On average, how many hours do you sleep each night?
Your answer
How do you normally cope with stress?
Your answer
READING, WILLING and ABLE to change.
How READY are you to change your behaviors and habits?
Not at all
1
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9
10
Completely
Clear selection
How WILLING are you to change your behaviors and habits?
Not at all
1
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3
4
5
6
7
8
9
10
Completely
Clear selection
How ABLE are you to change your behaviors and habits?
Not at all
1
2
3
4
5
6
7
8
9
10
Completely
Clear selection
Please list all obstacles or constraints to making and sticking with nutritional changes.
Maybe you have picky kiddos who don't eat anything other than mac n cheese. Maybe you associate nutrition plans with starvation. Maybe you have little time. These answers will be key to making the necessary changes.
Your answer
Please use this space to add any additional information that was not covered. If you are good to go then you are good to go.
Your answer
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