Nutrition is Easy Questionnaire

First Name

Last Name

GENERAL HEALTH & NUTRITION QUESTIONS

Personal Profile Information:

Birthday

Height

Current Weight

Current Bodyfat

Weekly Exercise Information:
Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.

Exercise/Activity

How many Days/Weeks

Duration

Lifestyle/Professional Activity:

How would you rate the activity level of your PROFESSION, or what you do during the day (non-exercise related)?

Your Goals:

What are your Goals?

What is your Goal Weight?

Protein Requirements:

Which best describes you?

Body Type:

Which of the following statements best describes you?

Health & Medical Conditions:

Select any that apply:

Food & Habits:

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also indicate the time and amount.

What are your favorite foods?

What are the foods you dislike?

What time do you normally wake up?

What time do you normally go to bed at night?

If you smoke, how many cigarettes do you smoke per day?

If you smoke, how many years have you smoked?

If you drink alcoholic beverages, what and how many per day?

Are you allergic to any types or kinds of food?

Have you ever been placed on any type of nutritional program in the past?

If yes, by whom and what did it consist of? Please explain

What were your results?

Have you ever had your bodyfat tested?

If yes, how was it tested and when?

BY CLICKING THE "SUBMIT" BUTTON BELOW, I AM AGREEING TO ALLOW JAMES SIMMPSON, WEIGHT MANAGEMENT CONSULTANT, TO DESIGN A WEIGHT MANAGEMENT PROGRAM FOR ME TO ENHANCE MY HEALTH & FITNESS GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD JAMES SIMPSON OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING HABITS. I UNDERSTANT THAT JAMES SIMPSON IS NOT A REGISTERED OR LICENSED DIETITIAN, NOR A MEDICAL PRACTITIONER. THIS WEIGHT MANAGEMENT PROGRAM DOES NOT REPLACE THE EXPERT ADVICE OR MEDICAL TREATMENT OF MY OWN PRIVATE DOCTOR. I HAVE GIVEN JAMES SIMPSON ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS.