Nutrition Questionnaire
Please fill out the form below as thoroughly as possible. This will help us to customize your plan to be most effective. Be sure to add any details you think might be important. If you forget any important information, please email julie@potentialenergytraining.com.
Name
Your answer
Phone Number
Your answer
Email address
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City, State where you live
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Age
Your answer
Gender
Height
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Weight
Your answer
Goals- Please describe what your goals are and what you hope to achieve from nutrition coaching
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Please describe your typical breakfast
Your answer
Please describe your typical lunch
Your answer
Please describe your typical dinner
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Please describe any snacks you eat throughout the day
Your answer
Please describe any beverages you consume throughout the day including water, coffee, soda, ect.
Your answer
Please describe your alcohol consumption throughout the week.
Your answer
Please describe what type of 'treats' you enjoy or your biggest food weakness.
Your answer
Please describe a typical week of exercise including duration and intensity.
Your answer
Please describe all of the food you eat before, during, and after exercise.
Your answer
How many hours of sleep do you get a night? How well do you sleep?
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Do you have any health or medical issues?
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Please list any food allergies or preferences that you have.
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Do you have support at home for making a commitment to change your eating habits?
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