LIFESTYLE AND HEALTH QUESTIONNAIRE

LIFESTYLE AND HEALTH QUESTIONNAIRE
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Age

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Height
Weight
What is your main reason for reaching out to Sheree?
How would you describe your present state of health?
Are you taking any prescription medication?
If yes, please list:
Do you take any over the counter medication?
If yes, please list
Do you take a multi-vitamin consistently?
When was the last time you visited a physician?
Do you have any medical conditions? Please describe:
What are your dietary goals?
What was your highest weight and at what age?
What was your lowest weight and at what age?
Have you ever followed a diet? Which one?
Have you tried to lose weight before? Please explain:
Are you following a special diet now? If yes, please describe.
What do you consider to be the major issues in your diet and eating plan? ( eating late? snacking? skipping meals? processed foods? )
How many glasses of water do you drink a day? (a glass is 8oz.)
Do you have any food allergies or intolerances?
If yes, please list:
How many times do you eat out a week?
What type of restaurants do you eat out at? Please list:
What foods do you crave?
Do you have any digestive issues?
How is your appetite affected by stress?
How often do you drink alcohol a week?
Do you smoke cigarettes?
Do you drink caffeinated beverages?
If yes, how many per day?
Do you workout now? Physical activities? Please describe:
How ready are you to adopt a healthier lifestyle
What type of exercise interests you?
How many hours do you sleep on weeknights? weekends?
⭐️ Please note that completing this screening process enables Sheree to review your application. Providing this information does not guarantee her services.
Please check each box to agree and acknowledge you have read below:
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