Personalized Nutrition Plan Questionnaire 25%Contact informationFirst Name*Last Name*Email Address*Phone number*How to contact you?*WhatsAppViberEmailNextBiological sex*MaleFemalePrefer not to discloseYear of birth*Height*Units*cmfeet/inchWeight*Units*kglbsWaist circumference*You will need: measuring tape (flexible meter) or string + ruler 1. Stand upright and exhale completely 2. Find the narrowest part - usually between the ribs and hips, at belly button level 3. Measuring - Wrap the meter or string around the waist and mark the place where it meets 4. Read the measurement from the meter or measure the string with a ruler Important: The meter/string should be firmly against the skin, but must not squeeze or indent the skinCircumference of the widest part of the upper arm*You need: measuring tape (flexible meter) or string + ruler 1. Relax your arm beside your body or bend it slightly at the elbow 2. Find the widest part - usually in the middle between shoulder and elbow 3. Measuring - Wrap the meter or string around the upper arm and mark the place where it meets 4. Read the measurement from the meter or measure the string with a ruler Important: The meter/string should be firmly against the skin, but must not squeeze or indent the skinCircumference of the widest part of the thigh*You will need: measuring tape (flexible meter) or string + ruler 1. Stand upright with legs slightly apart 2. Find the widest part - usually at the top of the thigh, just below the groin 3. Measuring - Wrap the meter or string around the thigh and mark the place where it meets 4. Read the measurement from the meter or measure the string with a ruler Important: The meter/string should be firmly against the skin, but must not squeeze or indent the skinBackNextWhat do you hope to achieve with this program?*Are you trying to lose or gain weight?*Lose weightGain WeightI just want to eat healthierWhat is your goal weight*Units*kglbsHealth conditionChronic diseases*Chronic diseases, list therapy you take and how you take medicationsList all supplements that you useVitamins, minerals, herbal / homeopathic preparations, extracts, teas...General conditions without specific therapyProblems with digestion, intestines, headaches, insomnia, tendencies towards certain diseases, insulin resistance, nervousness, fatigue, pregnancy/breastfeeding, rheumatic problems, etc...Surgeries or other surgical procedures in the last 6 monthsLifestyle habits and daily routineDaily obligations and other activities(e.g. shift work, how long they last and when during the day, time spent at home, rest periods, specify duration of exertion and rest during the day in as much detail as possible)Do you currently exercise?*YesNoWhat type of exercise / training / sports activity?How many times/days per week?How long? (minutes per day)Do you have any exercise limitations?*YesNoDescribe what exercise limitations you have.Sleep rhythmHave you ever deliberately induced vomiting, used laxatives, fasted, or exercised for long periods of time to lose weight? If yes, please explain.Regular bowel movement (every day)YesMostly yesMostly noBackNextEating PatternsThe type of diet you follow*Please selectStandard diet - typical mixed dietGluten-free - no gluten (for celiac disease)DASH - against high blood pressure, low sodiumFlexitarian - mostly plant-based with occasional meatFODMAP - for digestive issuesChrono diet - eating according to biological rhythmIntermittent fasting - periods of eating and fastingJapanese/Okinawan - fish, soy, seaweed, fermented foodCarnivore - exclusively animal productsKetogenic - very low carbs, high fatMacrobiotic - whole grains, minimally processed foodMediterranean - olive oil, fish, fruits, vegetables, grainsNordic - seasonal food, fish, game, berriesOMAD (One Meal A Day) - only one meal per dayPaleo - ancestral foods (meat, fish, fruits, vegetables)Pescatarian - no meat, with fish and seafoodRaw food - food not cooked above 46°C (115°F)Vegan - no animal products whatsoeverVegetarian - no meat or fish, with eggs and dairyOther (specify)Specify the type of diet you followHow many meals do you usually eat per day?*0-12-34+How many snacks do you usually eat per day?*0-12-34+How often do you skip meals?*NeverSeldomSometimesOftenAlwaysList the foods that you absolutely do not consume due to your health condition, food intolerance or allergy?*Name the foods you like to consume?*Name the foods you don't like to consume?*What type of beverage do you like?What are your beverage dislikes?Alcohol consumption?How much water do you drink per day (8 oz cups)?On average how many cups (8oz.) of caffeinated beverages do you drink per day?*(black tea, coffee or energy drinks)On average how many cups (8oz.) of sugary drinks do you drink per day?*(soda, sports drinks, juices)On average how often do you snack on convenience food*(chips, candy, granola bars, crackers, cookies)NeverSeldomSometimesOftenAlwaysWho does the meal preparation and cooking?I prepare meals.Somebody elseWhich of the following factors apply to your eating habits and current lifestyle? Check all that apply*Mark everything that applies to you.Likes healthy foodFast eaterRely on packaged/fast foodPlans mealsDo not plan mealsLate night eaterLives alone/eats aloneEats most meals at tableReads nutrition labelsKnows how to cookPrepares meals at homeEats a variety of foodsBackSendThis field should be left blank
