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Nutrition & Lifestyle Coaching Questionnaire
Please answer the following to the best of your ability
Email address *
Name *
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Phone # *
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​Are you currently being treated for any medical condition?
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​Do you have a family history of diabetes, high blood pressure, or high cholesterol?
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Are you taking any medications?
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​Are you taking any vitamins or nutritional supplements?
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​Have you ever dieted?
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Are you currently on and or have tried special diets (vegetarian, pescatarian, paleo, gluten free, etc)?
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​​How active are you on a typical work day?
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​Do you exercise? How often?
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Describe changes, if any, that you have made to your eating and/or exercise habits. When did you implement these changes?
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How often and to what magnitude do you experience stress?
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​How do you relieve stress?
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​How do you sleep? How many average hours per night?
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Do you drink alcoholic beverages/ how often/ how many?
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​Do you drink coffee/consume caffeine?
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Do you eat breakfast?
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How long does it take for you to eat an average meal/Do you take your time when you're eating?
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Do you have any known food allergies or are sensitive to certain foods/food groups?
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How often do you drink water and in what amount?
​Where do you eat most often?
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​Do you eat out? If so, how often?
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​What is your current energy level/ how do you feel?
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Why do you want to seek nutritional/lifestyle advice? Have you before?
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