Personal Fitness & Nutrition Development Questionnaire Page 3
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1
2
3Do you have any food allergies?
Yes
No
If yes, please explain:
How often do you eat?
6 or More Times a Day
3-4 Times a Day
Whenever Hungry
5-6 Times a Day
Strictly Breakfast, Lunch, and Dinner
Less Than 2 Times a Day
How often do you eat out?
Almost Every day
Less Than Once a Week
Less Than Once a Month
A Few Times a Week
A Few Times a Month
Rarely or Never
Are you currently on any special diet?
Yes
No
If yes, please explain.
Have you ever had a nutrition assessment done before?
Yes
No
If yes, please explain.
Prepare a 3-Day food journal and attach to this document or email to our dietitian. See example below:
Day 1
- Please be as specific as possible.
Time
Food/Drink
Amount Eaten
12:00pm
Turkey Sandwich
2 slices wheat bread, 3 slices turkey, 1 leaf lettuce, 1 slice tomato, 1 tsp. brown mustard
What days and times would you prefer to train and/or be contacted?
Trainer Preference:
Referred By:
1551 Mayview Road
Upper St. Clair, PA 15241
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