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Nutrition Clinic First Consultation Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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Pre-Consultation Questionnaire
1

What is your name and surname?

2

Provide your email address

Write an e-mail in the correct format
3

What is your primary goal?

Choose the main objective you want to achieve through the nutrition plan.
4

What is your age?

Please provide your age in years.
5

What is your gender?

Select your gender.
6

What is your ethnicity?

Specify your ethnicity.
7

How active are you?

Briefly describe your physical activity level including walking and exercising.
8

What type of exercises do you usually engage in?

Mention the types of exercises you commonly perform.
9

What has been a challenge for you in the past when trying to achieve your goal?

Share any challenges or difficulties you often face related to nutrition or health. It can be anything like you don't have the knowledge, it is difficult with your lifestyle, schedule, environment...
10

On a scale of 1 to 10, how satisfied are you with your current diet?

Rate your satisfaction level with your current diet, where 1 is very dissatisfied and 10 is very satisfied.
11

How many hours of sleep do you usually get each night?

Indicate the average number of hours you sleep per night. If its different every night provide a summary.
12

Do you have any known food allergies, intolerances or special requirements?

Specify bellow.

Well done! Now we can work together and you are one step closer to achieving your dreams.

See you soon...

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