Nutritional Questionnaire
Please fill out the form as accurately as possible.
Name *
Your answer
Gender *
Weight: *
Your answer
Height: *
Your answer
1. Please select the following categories of medications that you are currently prescribed and/or taking over the counter: *
Required
2. Please select any supplements that you are currently taking: *
Required
3. Please List Any Prescriptions or Other supplements:
Your answer
4. Energy Goals: "I'd like to..." *
Required
5. Longevity Goals "I'd like to..." *
Required
6. Body Composition Goals "I'd like to..." *
Required
7. Stress Reduction Goals "I'd like to..." *
Required
8. Are you interested in jump starting your goals? A 10 or 30 day cleansing program will be a great way to improve weight loss and energy levels. Are you interested? *
9. Food: check all of the following that apply. *
Required
10. Balanced Eating- check all of the following that apply. *
Required
11. Eating frequency- check the following that apply. *
Required
12. Activity level: *
13. Exercise frequency and schedule: *
Required
14. Digestion: do you experience any of the following? *
Required
15. How many bowel movements do you have per day? *
16. Do you use any of the following stimulants? *
Required
17. If you selected any of the above, please tell us how much each is used per day/week?
Your answer
18. How many cups (8 oz) of water do you drink a day? *
Your answer
19. On a scale 1 to 10 (1 being the lowest, 10 being the highest), what level of stress are you experiencing? *
20. How many hours of sleep do you average per night? *
21. Are you able to fall asleep? *
22. Do you suffer from insomnia or sleep disorders? *
23. Do you remember your dreams? *
24. Do you sleep with any electronic devices on (including light, tv, radio, computer, etc)? *
25. Do you often abruptly awake from sleep? *
26. Do you suffer from depression or mood swings? *
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