Nutrition Questionnaire

Date

Email

Name

First Last

Birth Date

Sex

Address

Street Address City State / Province / Region ZIP / Postal Code

Weight

Height

Lowest Adult Weight

Heighest Adult Weight

Nutrition Goals

Exercise Routine: # Days week

Duration

Current Medical Conditions:

Current Medications:

Current Supplements/Vitamins

Previous Diet Programs:

Where are most of your meals prepared?

Number of fast food meals a week:

Number of restaurant meals a week:

Number of Alcoholic Beverages Consumed Per Week:

Number of Fruits and Vegetables eaten a Week:

Food Allergies/Intolerances:

Healthy Habits Nutrition Consulting