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Nutrition Questionnaire
I am a Renaissance Periodization Nutrition Coach here to help you enjoy food while getting the results you’re looking for.
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Email
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Your email
Name:
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Your answer
Sex:
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Male
Female
Age:
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Your answer
Height:
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Your answer
Current Weight:
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Your answer
What is your body fat percentage? (If you don’t know that is okay, I will be able to estimate via pictures)
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Your answer
If we cannot meet in person, please send me full body photos from the front, back and side. Bathing suit or shorts and a tank top are most helpful. Rest assured, no one will see these photos other than myself. This will help me accurately determine your lean body mass in order to best program your diet to work for you.
What are your current eating habits? An example day of eating is a helpful way to give me this information. You can give me an example of your “best” and “worst” days if you tend to fluctuate in how you eat. This is a judgment free zone, I am just here to help you structure your eating to meet your goals.
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Your answer
Have you dieted for weight loss or gain before? If so, how recently, for how long, and what kind of diet was it? Did you maintain the changes and if so for how long? Feel free to give me as much detail as you can. This information really helps me understand your background so I can help you succeed.
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Your answer
On a scale of 0-10 (10 being most knowledgeable), how much do you feel you know about nutrition (calories, macros, etc.)? Feel free to explain your answer.
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Your answer
What questions do you have for me about diet/nutrition for body comp change and/or health?
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Your answer
What kind of exercise or training do you currently do (if any)? Please list any type of exercise and what a typical session (time, reps, sets, distances, etc.) look like for you.
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Your answer
How many years (if any) have you been training with weights?
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Your answer
Please list your wake time and bed time Monday-Sunday.
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Your answer
Please list your training days Monday-Sunday and the duration of those sessions.
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Your answer
Please list what type of training you partake in Monday-Sunday.
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Your answer
Please describe any times you cannot eat or any additional information that you think will be relevant to meal scheduling.
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Your answer
Will you have any big events, festivities, outings, travel, or other interruptions to your regular schedule during your time working with me? If so, please list below:
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Your answer
What is your ideal meal number per day if you could choose? (lower number= larger meals spaced further apart). Please circle one or more and feel free to explain below:
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3
4
5
6
7+
Other:
Required
Are there times during the day when you tend to feel most hungry or when you find you eat or snack the most?
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Your answer
What are your goals in terms of weight change?
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Your answer
What are your goals in terms of how you would like your body to look and feel?
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Your answer
How important are performance and health to you? Are you focusing on a nutrition plan to increase performance?
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Your answer
What is your imagined timeline for your goal?
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Your answer
What are you hoping for from a coach on your journey? (Accountability/to gain knowledge about how to diet/etc).
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Your answer
Why do you want to achieve your goal?
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Your answer
What personal values can you tie to this goal? (For example, do you want to be more fit in order to enjoy a hobby or because you value your health and want to live long and well?)
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Your answer
Have you tried to reach your goal in the past? If so, how did you go about trying?
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Your answer
If you have tried and missed the mark for your goal, what do you think got in your way?
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Your answer
What has been the hardest part of any previous diet or nutrition programs you have done?
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Your answer
What has been the easiest part of any previous diets or nutrition programs you have done?
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Your answer
On a scale of 1-10 (10 being top priority), how important are the fulfilling things in your life that make your fitness goals harder to reach with friends, relaxed dinners with spouses, and so on)?
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1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 (10 being top priority), how important are your fitness goals?
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1
2
3
4
5
6
7
8
9
10
Is there anything you think may be getting in the way of your fitness goals that you are unwilling or very hesitant to give up or minimize (even temporary) in order to reach goals? (Examples: wine on weekends, morning coffee drinks, favorite food, etc.)
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Your answer
On a scale of 1-10 (10 being most confident), how confident are you in your ability to be successful with your fitness goals.
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1
2
3
4
5
6
7
8
9
10
Do you think you have any habits that have helped you achieve in other areas in your life? If so, what are they? (It can be helpful to study the things we are successful at in order to learn to apply these strategies in other areas.)
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Your answer
What are things you think may have been getting in your way that you are willing to give up or minimize (at least temporarily) to reach your fitness goals?
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Your answer
Do you have any medical conditions or diagnoses that might impact your metabolism or your mental or physical health in any way? What, if any, medications do you take & what is its purpose?
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Your answer
I ask these last questions to help me understand how to write a program that will help you make progress towards your goals without completely disrupting the other awesome parts of your life. We all have our own specific balance and priorities and there is no shame in any choice. I just want to help you find your perfect place where you can feel happy in your life, but still move towards your fitness goals!
Next Steps: (take a screenshot)
1. Download FatSecret Calorie Counter via Google Play or App Store.
2. Setup your profile
3. Add me as your trainer:
gpete24375@gmail.com
4. If you’re looking for a scale for body fat/muscle mass measurements on Amazon: RENPHO or any smart scale will suffice. You can find them as low as $20 and they connect to your phone.
A copy of your responses will be emailed to the address you provided.
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