Nutrition - Questionnaire - Carla Fit Life

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Nutrition Questionnaire

* Indicates required field

Name *

First

Last

Age *

Height *

Current weight *

Your goal weight *

Gender *

Female Male

How would you describe your health? *

Excellent Very good Good Fair Poor

What are your goals with this program? *

Change/improve my eating habits Fat/weight loss Look/feel good Upcoming party Building lean muscle Body building Other

What time do you wake up and go to sleep? *

What is your profession?Do you have break for lunch, morning tea etc? *

Do you exercise? Frequency (weekly) *

Yes No 1-2 3-4 5 or more

Do you smoke? If yes, how many cigarettes a day? *

1-2 3-4 5 or more

How easy is it for you to gain or lose weight by changing your diet? *

Very easy Requires a lot of effort Very tough Not possible

Are you currently taking any medication or supplements? If yes, which ones ad what is the reason *

How often do you eat a full breakfast? *

Every morning 4-5 times a week 2-3 times a week Rarely

What is the main reason for not having a proper breakfast? *

Not hungry in the morning Not in a habit of having breakfast In a hurry

How often fo you have snacks or flavoured drinks (soda/fruit juice) between meals? *

More than 4 times a day 2-3 times per day A few times per week Hardly ever

How often do you eat fast food (such as burgers, shakes, take-away or pizza)? *

More than 4 times per week 2-3 times per week About once a week Hardly ever

How many times do you eat in a day, including snacks? *

1-2 3-4 5 or more

Do you eat lollies, chocolates, biscuits etc? If yes, how often? *

1-2 times a day 2-3 times per week Once a week Hardly ever

How many glasses of water do you drink in a day? *

0-2 3-4 5 or more

How often do you eat whole grain foods (such as brown bread, wholemeal pasta and oat meal) and how often do you eat refined grain foods (such as cakes, white bread, normal pasta and pastries)? *

Always whole grain food Always eat refined grain foods Both types in equal proportion

Where do you get most of your protein from? Is it from non- veg food such as meat and eggs or veg. foods such as soy and nuts? *

Only veg. Always non-veg. Both types in equal proportion

Do you have any food allergies or food intolerance? If yes, please list here *

Do you have any health problems such as diabetes, high blood pressure, high blood cholesterol? If yes, please list here *

Please note that if you answered yes to the above question we will need a written authorization from your physician to start this program

18. What is your favourite food? What foods/ingredients do you dislike? *

Dislike *

Comments *

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