Panther City Nutritional Counseling Questionnaire

Full Name*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

What is your birthdate?*

MonthDayYear

Describe briefly what you want out of a nutritional counseling session*

What other nutritional counseling or education have you received in the past? (books, blog, hospital, school, college class, nutritionist, etc)*

What do you want to change about yourself? *

What questions would you like answered in regard to nutrition?*

List the 5 food groups*

Have you ever tried to loose weight?*

YesNo

If you have tried to loose weight in the past, what all did you do?

On a scale of 1-5, how motivated would you be to keep up with a daily food diary?*

Vegetables. Do you 1 (really dislike), 5 (like and eat often)*

Do you have any food allergies or sensitivities?*

What is your attitude toward cooking? On a scale of 1-5 . . .*

How often in 7 day week do you eat out?*

How many drinks of alcohol do you imbibe/week?*

How often do you have sweets/dessert?*

When you eat your meals, are you usually doing something else as well? i.e.-texting, working, watching TV*

On a scale of 1-5, what is your attitude toward cooking?*

How frequently are you fatigued throughout the day?*

Do you take supplements? If so, list the kind of supplement (fish oil, multi-vitamin) and the brand.*

What foods are your "cheat foods"? List them*

Do you own a food scale and measuring spoons and cups?*

What does your breakfast routine look like? Describe it*

Do you crave certain foods? List them*

Besides alcohol, what other beverages do you usually drink? Juice, sweet tea, water, etc. Please list all*

What percentages of the beverages you imbibe are water/juice/coffee/alcohol? For example- 50% soft drinks/ 25% water /25% coffee. Give your best guess*

List all the medications you are currently taking*

Please list any past injuries and surgeries*

What is your height (inches) and weight (pounds)? Separate height and weight numbers by a comma*

Give your typical physical activity routine for the week*

"Physical activity is any body movement that works your muscles and requires more energy than resting" - http://www.nhlbi.nih.gov/health/health-topics/topics/phys/

*Walking, running, dancing, swimming, yoga, and gardening are a few examples of physical activity.

Exercise is a type of physical activity that's planned and structured. Lifting weights, taking an aerobics class, and playing on a sports team are examples of exercise.

Hello! Thank you for completing the questionnaire. Your answers will assist me in helping you meet your nutrition goals. Panther City Nutritional Counseling assists with weight loss, leaning out, and wellness/cleaner eating. Upholding everyone as unique physiologically, I counsel based on individual nutritional needs.

Important items regarding a counseling session:

In most cases, we’ll need to measure your body fat % in a counseling session as this helps hone in on a specific and quantifiable goal.

I may require you to log your meals each day. This is a commitment and can become easier as you are consistent.

Before agreeing to a 6 week coaching session, you must own a food scale and measuring cups and spoons.

Whether you need to lose weight or eat cleaner, reaching your nutrition goals requires planning--a dedication on your end.

I uphold to keep confidential information with respect to you.

Thank you!