Questionnaire for Wellness, Weight Loss, or Custom Meal Plan

Fill Out Your Information Below

Name:

Email:

Phone:

Address

City

State

Zip

Age:

Height

Current Weight

Ideal Weight

What are your chief complaints, diagnoses, or concerns?

What are your goals for health or weight loss?

What have you tried before to address these?

Do you have a "food philosophy" (way you eat or like to follow) and why?

Are you taking any medications? If so, list name and/or purpose:

Do you take any supplements? List name and purpose of each:

Describe a typical breakfast (be specific)

Describe a typical lunch (be specific)

Describe a typical dinner (be specific)

Do you have any allergies?

Do you prep your own food? If not, are you willing to prep?

Are there foods you will not eat?

How often do you eat out or order out?

Describe any obstacles you foresee in moving forward toward your goals

How much water do you drink per day?

What other beverages do you consume and how ofter?

Do you exercise (y/n)? Describe type and frequency:

Do you have any specific questions for me?

If you knew my recommendations would get you to your goals, how willing are you to comply?

If there anything else you think would be helpful for me to know?

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