| A.
Reduce body fatYes
No |
|
| B.
Lose weight Yes
No |
C.
Improve nutrition ( health reasons, for
competitive body building, gain weight,
lose body fat, etc)
YesNo |
D.
Improve overall appearance (
competitive body builders, models,
weight loss)
Yes
No |
E.
Increase energy and overall fitness
Yes
No |
| 2.
Additional Health Considerations: |
1.
Improve cardiovascular profile (Heart
health-lower cholesterol, lower
triglycerides-lower blood pressure)
Yes
No |
| 2.
Heart Disease Yes
No |
| 3.
High blood pressure Yes
No |
| 4
.High blood cholesterol YesNo |
| 5.
High triglycerides Yes
No |
| 6.
Diabetes Yes
No
|
| 7.
Alcohol/substance abuseYesNo |
| 8.
Smoke tobaccoYes
No |
|
9.
Taking prescription drugs regularly
Yes
No |
|
|
|
|
Diet
and Nutrition
|
|
3.
Primary Nutrition Goal
Improve
Overall Nutrition
|
|
| Lose
Weight (lose fat and/or lose weight) |
|
| Gain
Weight (increase lean body mass,
decrease fat) |
|
| Maintain
Weight (stay the same weight) |
|
4.
Special Needs (Choose any that
apply):
Heart
Healthy Diet (Diagnosed with Heart
Disease, high cholesterol, etc)
Lower
Sodium Diet (Diagnosed with High Blood
Pressure, etc)
Lactose
Free Diet
Dairy
Free Diet
Vegetarian
Diet
Vegan
Diet
Diabetes
Other Special Need: |
|
5.Nutrition
When you eat do you...
Eat
mostly home-cooked meals (prepared from
recipes or "scratch")
Eat
about 1/2 home-cooked and 1/2
convenience or restaurant meals
Eat
mostly convenience/packaged foods
Eat
mostly fast foods or restaurant meals |
|
Mark
the answer that best describes the
nutrition quality of your current diet:
It's nearly
optimal
It's pretty good, but needs some
fine-tuning
I eat mostly what I want and haven't
worked on improving my diet |
|
Current
diet
(Choose any that apply):
I
take vitamin/mineral supplements
I use protein powder/protein drink
supplements
I
use energy boosters (caffeine, creatine,
etc.)
I take
herbal dietary supplements
I take
weight loss pills, diuretics,
carbohydrate blockers, or fat blockers |
|
What
kind of diet best defines your current
eating style?
Typical
Diet (high fat, high salt, restaurant
foods, no diet changes yet)
Low
fat, high protein
High
fat, high protein
Low
fat, average protein, high carbohydrate
High
fat, low carbohydrate, moderate to high
protein (low carb diet)
Mediterranean
type diet
Other
cultural diet (Asian, Middle Eastern,
African, other)
Special
diet (vegetarian, dairy free, allergy)
Medical
needs diet
Not
sure of diet composition
|
|