NUTRITION QUESTIONNAIREIn order for me to get a better understanding of your HEALTH, daily activity, and nutrition intake, please fill out the questionnaire below. PERSONAL PROFILE Full Name * First Name Last Name Email * What city and state are you located in? * How did you hear about my services? * Current Weight (lbs.) (best estimate or put n/a if unknown) * Height (ft' inches") * Gender * Female Male Prefer not to say Date of Birth * MM DD YYYY Age * FITNESS AND NUTRITION - CURRENT Health and Fitness Goal * Select One Lose Weight: lose 10+ lbs Build Muscle: build muscle and increase body weight Athletic Performance: optimal nutrition to support intense athletic training. minimal to no weight change Body Recomposition: lose less than 10 to 15 pounds of body fat, while simultaneously building muscle Improve Health: improve nutrition and health while maintaining current weight Goal Weight (lbs) Date to Reach Goal Weight MM DD YYYY Weekly Exercise * Select One Very Light: Almost no purposeful exercise Light: 1-3 hours of gentle to moderate exercise Moderate: 3-4 hours of moderate exercise Intense: 4-6 hours of moderate to strenuous exercise Very Intense: 7+ hours of strenuous exercise Daily Activity Level (not counting exercise above) * Select One Very Light: Sitting most of the day, for example, desk job Light: Sitting, standing, and light activity, for example, teacher Moderate: Continuous gentle to moderate activity, for example, restaurant server Heavy: Strenuous activity throughout the day, for example, construction worker Dietary Preference * Select One Anything Mediteranean Paleo Vegetarian Ketogenic Fully Plant-Based Macronutrient Ratio * Select One Balanced (30% Protein, 35% Carbs, 35% Fats) Low Carb Low Fat Very Low Fat Custom Macro Percentages Custom Macro Grams Number Meals Per Day Including Snacks * FITNESS AND NUTRITION - PAST AND/OR FUTURE Tell me a little more about you. What additional nutrition information or lifestyle/habits would you like to include on your profile? Be as detailed as you like. The more information I have the more custom and helpful our consultation will be. HEALTH SUPPLEMENTS Are you hitting a plateau or not hitting your nutrient goals with food items alone? Supplements can aid and accelerate your fitness goals! What supplements are you interested in below? Check one or all that apply. Protein Powder Multi-Vitamins Powder Greens Fat Burn Thermogenic Intra Cleanse EFAs Pre-Workout (caffeine and no caffeine options) Sleep Aids BCAAs Testosterone Other Thank you! I’ll get back to you within 1-3 business days. Nez is a PN Level 2 Masters Coach. A portion of this questionnaire is designed by Precision Nutrition.
