New Client Questionnaire

New Client Questionnaire
Name

First Name Last Name
Phone number
Occupation
Student, desk job, labourer etc.
Height
Current Weight
Has your weight changed recently or does it regularly change?
Give details of changes and weights you fluctuate between.
Purpose of this consult. Why do you want to meet? What are your goals?
Any medical conditions and medications I should be aware of?
If you take medication for any conditions please include that too.
Are you currently taking any supplements? Including protein powders?
Please give details of what supplements and frequency of use.
Do you have any mental health issues or concerns I should be aware of?
Eg. Depression, anxiety.

Rate your stress levels.

	1	2	3	4	5	6	7	8	9	10

1 is Very relaxed, 10 is Highly stressed

Digestion
Do you have any allergies or food intolerances?
If yes, please give details.
Do you have any diagnosed gastrointestinal conditions?
Eg. Inflammatory bowel disease
Please check any of the following gastrointestinal symptoms you regularly suffer from:

Gas Constipation Diarrhoea Bloating Pain Nausea Reflux
Eating Habits
How many meals a day do you eat?
Do you snack? If so, how often and what foods do you choose?
How many times per week do you eat out, order takeout or eat ready meals?
Give details of what foods you usually choose
Do you feel that you eat out of comfort when you are stressed or upset?
If so, how does this change your food choices?
Are you happy with your diet? Do you feel well nourished?
If not, please state what you are unhappy with
Do you like to cook? Do you find cooking difficult? If so, why?
This helps me come up with suggestions for you
Does your diet have a lot of variety, or do you stick to "safe foods"?
Do you dislike, avoid or hate any foods?
This helps me come up with better suggestions for you.
Do you currently follow any diet rules? Eg. dairy-free or a 5:2 diet?
Physical Activity
How many days/times per week do you actively exercise?
What exercise do you do and for how long?
Eg. 60 min weight lifting, 30 min running

How happy are you with your body and appearance?

	1	2	3	4	5	6	7	8	9	10

1 is Strongly dislike, 10 is I love it

What do you hope to accomplish with me?
Eg . Fat loss, more energy, more muscle, better relationship with food.
Anything else you want to share?
Should be Empty:

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Digestion