Nutritionist Consultation Questionnaire

Your Gender Your Gender Male Female

First Name

Last Name

Phone Number

Email Address

Age

Your Height

Your Current Weight

Desired Weight

Neck volume (cm)

Chest volume (cm))

Waist volume (cm)

Hip volume (cm)

Your Blood Type*

Do you exercise? If yes, what type of exercise and how often?

How many hours do you sleep on weekdays? How many hours do you sleep on weekdays? 6-8 hours Less than 6 hours 8 or more hours No sleep schedule, suffer from insomnia or frequent awakenings

Why do you need a nutritionist consultation? What do you want to adjust?

How many meals do you usually have per day?

Briefly describe your daily diet, starting with breakfast.

Do you take vitamins or dietary supplements? If yes, which ones and in what dosage?

Do you have any allergies?

Do you follow any specific dietary system? Do you follow any specific dietary system? Yes, vegetarian Yes, veganism Yes, other No

Do you consume alcohol? Do you consume alcohol? Yes, 3–4 times a week Yes, 1–2 times a week No, only on special occasions I don’t consume alcohol at all

Do you have a dependency on coffee/caffeine? Do you have a dependency on coffee/caffeine? Yes, I can’t live without coffee I’m not sure, I drink 1–2 cups of coffee or tea No

Do you smoke? Do you smoke? Yes No

Do you have regular bowel movements? Do you have regular bowel movements? Yes No

Your 5-day food diary (include weekends). The diary is a free-form description of everything you ate and drank during the day.

Do you take any medications? Including birth control pills?

Do you have any chronic diseases?

Do you have Type 1 or Type 2 diabetes?

Do you have a coating on your tongue? Please describe.

Do you have any skin conditions (e.g., dermatitis, psoriasis, itching, acne, etc.)?

Is your menstrual cycle regular?

When was your last visit to a gynecologist?

Do you experience thrush or other symptoms of candidiasis? Do you experience thrush or other symptoms of candidiasis? No Yes, a few times a year Often

Are you planning to get pregnant within the next year? Are you planning to get pregnant within the next year? Yes No

Do you have children? Do you have children? Yes No

Have you had unsuccessful or complicated pregnancies? Have you had unsuccessful or complicated pregnancies? Yes No

Do you suffer from low or high blood pressure? Do you suffer from low or high blood pressure? Yes, high Yes, low No Yes, low, and I often faint

Do you feel full of energy at the end of the day? Do you feel full of energy at the end of the day? Yes No, I can barely make it to bed More yes than no More no than yes

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