Nutrition Questionnaire

Please read carefully and answer accurately. All fields marked with an * are required. Please put N/A if not applicable. Thank you!

Personal Details

Questions

GOALS

  1. What is your 6 Week SMART Goal? (specific, measurable, achievable, relevant, and time-bound)

  1. What is your lifetime goal?

  1. Anything preventing from achieving those goals?

HEALTH HISTORY

  1. Please provide a list of your past Injuries/surgeries/hospitalizations.

  1. Any history with depression or anxiety?

  1. Any other medical diagnosis?

  1. Any other health concerns?

MEDICATIONS / SUPPLEMENTS

  1. Do you have any active prescriptions? If yes, please list down the name and dose.

  1. How frequent do you take your medication?

  1. List any vitamins/supplements you take regularly.

GUT HEALTH

  1. Please indicate the frequency of your bowel movements.

  1. Please indicate the consistency of your bowel movements.

  1. Any gut health concerns (GERD, IBS, etc)?

  1. Select the number that corresponds to the color of your urine. (Please refer to the chart below)

*

SLEEP

  1. How well do you sleep on a scale of 1-5? 5 being AWESOME.

*

  1. How well do you fall asleep on a scale of 1-5? 5 being AWESOME.

*

  1. How well do you stay asleep on a scale of 1-5? 5 being AWESOME.

*

  1. Do you have a method for tracking sleep (Fitbit, Apple Watch, Oura Ring, etc)?

DIETARY RESTRICTIONS

  1. Anything you can’t eat, won’t eat, don’t like, or are allergic to?

Habits/Behaviors

  1. List down any habits/behaviors you don’t like & want to change?

  1. Any habits/behaviors you wish you were doing but can’t seem to stick to?

  1. What do you usually have for breakfast?

Elevated Fitness