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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)
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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?
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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)?
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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
*
Submit
Oi!
FIT Comigo - Plano Básico
Programas- Português
Booty Bands
Galeria
Contato
Depoimentos