Nutrition Questionnaire

Part 1: Background Information
What is your first name?*
What is your last name?*
What is your date of birth? (month/day/year)*
MM slash DD slash YYYY
Gender*
- Male
- Female
What is your current weight in pounds?*
What is your height in feet and inches? (Remove shoes before measuring.)*
What is your body fat percentage (if known)?
What is your occupation?*
How would you describe the level of activity at your job?*
- Sedentary, I sit all day
- Moderately active
- Very active
Please describe your current health and fitness goals*
Please describe your timeline for achieving your health and fitness goals*
Part 2: Nutrition
Please describe in as much detail as possible a typical day of eating for you. Please include approximate times (ex: 8am), locations (ex: at my desk), and sources (ex: delivery from Energy Kitchen) for all food and beverages that you consume during the day. The more detail the better!*
How often do you eat breakfast?*
- Everyday
- Sometimes
- Rarely
Do you take nutritional supplements?*
- Yes
- No
If yes, please specify the supplement, dose, and frequency.
What 'healthy' foods do you enjoy eating?*
What foods do you dislike and avoid eating?*
Do you have any dietary restrictions?*
How often do you plan your meals in advance?*
- Always
- Sometimes
- Never
Do you cook and prepare the majority of your food?*
- Yes
- No, my spouse or partner does
- No, I eat out or order in a majority of the time
How often do you go food shopping?*
- Daily
- 2-3 times per week
- Once per week
Do you eat on a particular schedule?*
- Yes, I have a predefined eating schedule
- No, I just eat whenever I feel like it
If yes, please specify your ideal eating schedule:
What diets or dietary approaches have worked for you in the past?*
What diets or dietary approaches have NOT worked for you in the past?*
What are the 2-3 biggest nutritional roadblocks that are in the way of you achieving your health and fitness goals?*
Part 3: Training
Nutrition and Exercise are tightly linked. In order to maximize the results from your nutrition program, we need as much information as possible regarding your training program so that the two can be integrated.
What is your training experience?*
- Beginner (less than 6 months)
- Beginner-Intermediate (6-12 months)
- Intermediate (1-2 years)
- Intermediate-Advanced (2-5 years)
- Advanced (5+ years)
Please describe your current exercise schedule (including type of exercise, time of day, and duration of exercise). List each day of the week, and details for each day. Indicate "none" if nothing is scheduled on a particular day.*
Part 4: Health History
Your nutritional program has a profound effect on your body weight and health. It is important that we know as much as possible about your health so that we can craft a nutritional program that is the most appropriate and effective for you, based on your current and past health history.
Have you been diagnosed with any medical conditions?*
Do you currently take any prescription or non-prescription medications?*
Do you currently, or have you recently, sought out alternative treatments for injury or illness?*
Part 5: Sleep
The first series of questions are taken from the Epworth Sleepiness Scale, a scientifically validated measurement of daytime sleepiness. It is designed to determine how likely you are to fall asleep in a handful of different common life situations.
Sitting and reading*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Watching TV*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Sitting, inactive in a public place (e.g. theater or meeting)*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
As a passenger in a car for an hour without a break*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Lying down to rest in the afternoon when circumstances permit*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Sitting and talking to someone*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
Sitting quietly after lunch, without alcohol*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
In a car, while stopped for a few minutes in traffic*
- I would never doze
- Slight chance of dozing
- Moderate chance of dozing
- High chance of dozing
What time do you go to bed at night?*
What time do you wake up?*
Do you sleep completely through the night?*
- Yes
- No
If no, how many times do you wake up on average?
Do you take any supplements, drugs, or any other aids to help you sleep at night?*
- Yes
- No
If yes, please specify:
Part 6: Stress
The first group of questions are part of the Mindful Attention Awareness Scale, a psychological test used to rate your level of 'mindfulness'. This is related to your ability to self-regulate behavior as well as stress.
I could be experiencing some emotion and not be conscious of it until sometime later.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I break or spill things because of carelessness, not paying attention, or thinking of something else.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I find it difficult to stay focused on what's happening in the present.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I tend to walk quickly to get where I'm going without paying attention to what I experience along the way.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I tend not to notice feelings of physical tension or discomfort until they really grab my attention.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I forget a person's name almost as soon as I've been told it for the first time.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
It seems I am "running on automatic", without much awareness of what I'm doing.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I rush through activities without being really attentive to them.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I do jobs or tasks automatically, without being aware of what I'm doing.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I find myself listening to someone with one ear, while doing something else at the same time.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I drive places on 'automatic pilot' and then wonder why I went there.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I find myself preoccupied with the future or the past.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I find myself doing things without paying attention.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I snack without being aware that I'm eating.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
I use food to cope with stress.*
- Almost Always
- Very Frequently
- Somewhat Frequently
- Somewhat Infrequently
- Very Infrequently
- Almost Never
What is currently the biggest source of stress in your life?*
On a scale of 1-10, how would you rate your current level of stress? (1=no stress at all, 10=you are constantly stressed and fear it may be affecting your health)*
Part 7: Social Support
The following Social Support Questionnaire was developed by Precision Nutrition, LLC
Do the people with whom you spend each day (at work or at home) follow healthy lifestyle habits such as exercising regularly, watching what they eat, and taking nutritional supplements?*
- Yes, most of them do
- About half do and half don't
- No, most of them don't
Does your spouse or partner follow healthy lifestyle habits such as exercising regularly, watching what s/he eats, and taking nutritional supplements?*
- Yes, my spouse/partner does
- No, my spouse/partner does not
- I do not have a spouse/partner
When you want to perform some physical activity such as going for a workout or taking a hike, is it easy for you to find a partner to go with you?*
- Yes, it is easy to find a partner
- Yes, but very infrequently
- No, they never do
At your workplace, do your coworkers regularly bring in treats like cookies, donuts, or other snacks?*
- Yes, they often do
- Yes, but I typically don't indulge
- No, they do not
If you go out to eat more than once per week, do the people you dine with order healthy selections?*
- Yes, they often do
- Yes, but I typically don't indulge
- No, they do not
Do you belong to any clubs, groups, or teams that meet at least twice per week and do some physical exercise? (this does not include a health club membership)*
- Yes, I've been a member for years
- Yes, I've just started
- No, I don't
Do you train at PEAK Performance and/or another health club, on average, at least three times per week?*
- Yes, I've been doing this for at least one year
- Yes, I've just joined
- No, I don't
When discussing your nutrition and exercise goals with friends, do they seem interested in getting on board, or do they think you're crazy?*
- They are very interested
- They are not interested
- They think I am crazy
Do the people you live with bring home foods that aren't considered healthy or good for you?*
- Always
- Sometimes
- Never
- I live alone
Do the people you live with bring home foods that ARE considered healthy or good for you?*
- Always
- Sometimes
- Never
- I live alone
Do the people you live with or work with schedule activities for you that interfere with your pre-established exercise time?*
- Always - they do not respect my time
- Sometimes - they do not think about it
- Never - they respect my time
Do those around you bring nutrition, exercise, or supplement information to your attention so that you can stay informed about these topics?*
- Always
- Sometimes
- Nver

Part 1: Background Information

Part 2: Nutrition

Part 3: Training

Part 4: Health History

Part 5: Sleep

Part 6: Stress

Part 7: Social Support