Tatiana E. Abend
Nutritional Consultant
Tel:+34 971 613 876
+34 608 060 541
tabend@btlink.net
Nutrition Profile Questionnaire
Name:
Date:
YOUR NUTRITION PROFILE
1. In general, would you say you eat a balanced diet? 9 Yes 9 No
2. How many times do you eat in one day on the average?
3. What types of food don’t you like?
4. What types of food do you prefer?
5. At what time of the day are you most hungry?
6. Who cooks in your home?
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7. Do you eat out or at work/ school? Check one
9 Frequently
9 Once in a while
9 Never
8. Do you like to snack? 9 Yes 9 No Frequently? 9 Yes 9 No
9. What do you usually eat during a normal day?
G Breakfast Time:_________
G Late morning Time:_________
G Lunch Time:_________
G Afternoon snack Time:_________
G Dinner Time:_________
10. Can you do without food for many hours?
11. What time do you wake up in the morning?
12. How much water or tea, liquid, do you drink each day on the average?
13. How much coffee/tea do you drink each day?
14. Do you drink alcoholic beverages? Check one
9 Once in a while 9 Regularly
9 With meals 9 Never
If yes, list beverage(s) of choice
15. How many times a day do you eat raw, fresh fruit/vegetables?
16. What is your occupation?
17. Do you have any illness you are aware of?
18. Are you taking any kind of medication?
19. Are you taking any vitamin supplements or herbal remedies? If yes, list:
20. Are you allergic to anything? If yes, list:
21. Does your digestive system run ‘regularly’?
22. Do you practice physical activity?
23. If yes, how much time do you spend each week on a physical activity that makes you sweat, such as walking or strenuous physical work?
9 at least 150 minutes a week
9 maybe 100 minutes a week
9 usually zero minutes a week
24. You need to get to the third floor of a tall building. Will you
9 take the stairs and consider it a mini-workout
9 take the stairs, but huff and puff a bit
9 take the elevator
25. You watch TV this often:
9 one hour a day
9 2 hours a day
9 2+ hours a day
26. Which word best describes your ability to handle stress?
9 excellent
9 fair
9 poor
27. How many hours of sleep do you usually get at night?
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9 7and 1/2 hours+
9 6-7 hours
9 Fewer than 6 hours
28. Do you find your energy steady during the course of a normal day?
9 Yes 9 No
29. Does your weight and general health condition disturb you in any way?
9 Yes 9 No
30. Are you open to a new nutritional method adapted to your lifestyle?
31. In what areas would you most like to see a change or improvement?
Questions for weight loss clients:
32. When did your weight gain begin?
33. What would you view as the causes or circumstances of the weight gain?
34. How many children have you had?
9 Children 9 None
35. Have you tried diets before?
9 Yes 9 No
36. What kind of diets, which ones?
37. What results did you obtain?
38. What is your usual weight?
39. What is a weight you are comfortable with?
40. Which weight is your goal?
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41. Do you go on diets regularly?
9 Yes 9 No
42. Do you go on diets intermittently?
9 Yes 9 No
43. What is your motivation, on a scale of 1-5, to lose weight?
9 A physical problem
9 An aesthetic problem
9 A medical problem
9 A professional problem
44. What are your objectives in trying a new nutritional method, weight loss method?
45. How is the reaction in your home to you starting a new program?
9 Favorable
9 Opposed
9 Neutral
46. Would you like to be contacted concerning a personal dietary analysis/makeover?
9 Yes 9 No
47. Are you interested in related topics in health/well-being/beauty?
If yes to answers 46 and/or 47, please fill in the following.
Name:
Address:
Phone:
e-mail:
Today’s Date:
All information above is for nutritional profile only, confidential and provided without any obligation whatsoever.