Nutritional Coaching Client Questionnaire

The questionnaire below contains some personal questions. I ask these questions so I can really get a feel for who you are and what makes you tick. Please answer the following questions as honestly as possible. One of the most important aspects of the process you are about to begin is and open and honest relationship. In order to best serve you I need to know as much about you as possible. Feel free to write a novel in the notes section at the end of this questionnaire.

Basic Information

Name *

First

Last

Age *

Date of Birth *

Email *

Cell Phone Number *

Goals

What is the #1 goal? *

Are you willing to make sacrifices with your time, your social life, and even your sleep to reach that goal? *

Yes
No
Maybe

What do you see being the biggest challenges for you to accomplish your goal? *

Other *

Do you have a timeline for achieving that goal? If so, please specify: *

Additional Comments or Concerns pertaining to your goal(s)

Current Fitness Activity

Are you doing any workouts currently? If so what kind of workouts and at what frequency? *

What are your most and least favorite workouts? *

Do you have any physical limitations? (asthma, bad knees, bad wrists, etc) *

If you have a more regular schedule, do you work days, afternoons, or nights? *

Do you travel for your work? If so how often? *

Do you commute to and from your job? If so how long is your commute? *

Have you ever tracked your calories *

Yes
No

If you answered yes, do you feel it helped you with your weight loss goals? *

Lifestyle Information

What do you do for a living? *

What is the activity level at your job? *

None (seated work only)
Moderate (light activity such as walking)
High (heavy labor, very active)

Does your job involve shift work? *

Yes
No

Diet and Nutrition Information

Do you take any nutritional supplements? If so, what supplements and what dosage? *

Additional Comments

Height

Weight

Multiple Items *

INTRODUCTORY PLAN
30 DAY PLAN

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