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Detailed Nutrition Consult Questionnaire
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Name
*
First
Last
Email
*
Phone
*
Gender
*
Male
Female
Weight
*
Desired Weight
Height
*
Age
*
Education
*
Occupation
*
Marital Status
*
Work Hours/Rough Schedule
*
Major Family Responsibilities
People in the Household and their Relationship to You
Any Food Allergies or Intolerances?
Religious/Cultural Restrictions?
Brief Medical History
Abnormal Lab Values as of Recent? Dates Please.
Are you on any prescription or OTC medications?
Do you take any vitamin/mineral/herbal supplements?
Do you take any dietary supplements? (pre/post workout, etc)
Have you had any GI Issues? Please Explain.
Aching muscles or joints other than normal workout stress?
Depression? Diagnosed Eating Disorders or any other medical history that affects the way you eat or train?
Do you use tobacco?
Yes
No
Do you consume alcohol?
Yes
No
If yes, what kinds and how often?
Average Hours of Sleep Per Night?
Which Describes Your Sleep Best?
Restful
Mostly Restful
Interrupted/Restless
Insomnia/Hard to Sleep
On a scale from 1 to 5, how would you rate your daily stress level?
1
2
3
4
5
Do you have any big life changes coming up that could cause stress?
How do you generally cope with stress?
On a scale from 1 (not ready) to 5 (very ready), how ready are you to make a lifestyle change?
1
2
3
4
5
On a scale from 1 (not ready) to 5 (very ready), how confident are you in making a lifestyle change? (copy)
1
2
3
4
5
Who prepares your food and how often for most meals?
Write down what a typical day of food and beverage intake looks like for you. Not how you want to eat, but what you are currently doing. BE HONEST. Include time, place, foods consumed, amounts, and how much time you have to prepare for each meal for Breakfast, Lunch, Dinner, and any snacks
Do you use a list or plan to buy groceries?
Yes
No
Who buys, where, and how often do buy groceries?
Please describe your current hydration plan (daily, pre, during, and post workout)
Please describe your current pre workout fueling plan
Please describe your current during workout fueling plan
Please describe your current post workout fueling plan
What are your biggest barriers for eating healthy?
Are there any foods you absolutely won't eat or cook with?
Are there any foods you really love?
One or two things you would change about your diet
Please give a rundown of a normal training week (Mon-Sun, duration and intensities, total hours)
What is your main sport?
What is the name and date of your goal race or races (if applicable)
What are the conditions of your goal race?
Hot and humid
Very Cold
Hilly
Ultra Endurance
Very High Intensity
Self Supported (no aid stations)
Click all that apply
What current supplements/products/foods do you prefer or know you want to use on race day?
What products will the event have on course? (If known)
Do you have GI disturbances during races or training?
*
Often
Rarely
Never
Do you cramp during races or training?
*
Often
Rarely
Never
Do you struggle in the high heat and/or humidity?
*
Often
Rarely
Never
Do you struggle with muscle pains, stress fractures, or severe soreness that impairs your ability to be consistent with your training plan?
*
Often
Rarely
Never
What are one or two goals you'd like to achieve with the help of your dietician?
Email
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