Nutrition Questionnaire - Inertia Fitness and Nutritional Coaching

Initial Assessment Questionnaire

First Name

Last Name

Date

Cell Phone Number

Are you on Instagram? If so, what is your profile name?

What are your goals for this nutritional program:

Have you followed some form of diet/nutrition plan before? (ie. Keto/Noom/low carb/etc) If yes, what was your experience like?

Are you ready to make some changes to habits and mindset?

Yes No

Have you tracked macros before?

Yes No

If you have tracked macros before, did you find anything challenging?

Height

Weight

Age

Please list any food aversions/allergies or anything you simply do not like to eat ☺ (in particular proteins such as eggs, tuna, cottage cheese, yogurt, pork, etc)

Do you currently use a protein supplement/shake?

Yes No

If so, what is the amount of protein/carbs/fat per scoop and how much (in grams) per serving/scoop?

If you don’t currently use a protein shake are you open to trying one? (they are an easy and efficient way to get protein which is a driver in both fat loss & muscle build)

Yes No

Do you have any medical situations or special circumstances regarding nutrition?(ie. Diabetes, hypoglycemia, etc)

What supplements/vitamins do you take? (if any)

What would a typical week of fitness activity look like (please indicate day and length of activity including walking)

What would a typical week day look like in terms of wake time/eating/beverages(coffee, tea, alcohol, juices, water, etc)/bedtime (please use the table below to record meals and snacks as per a typical day and include approximate time of day. Use only the boxes needed for meals/snacks:

Typical Weekday

Wake Time

Wake Food/ Beverages

Meal 1 Time

Meal 1 Food / Beverages

Snack Time

Snack Food / Beverages

Meal 2 Time

Meal 2 Food / Beverages

Snack Time

Snack Food / Beverages

Meal 3 Time

Meal 3 Food / Beverages (please give 3-5 examples)

Snack Time

Snack Food / Beverages

Bedtime

Bedtime Food / Beverages

Typical Saturday

Wake Time

Wake Food/ Beverages

Meal 1 time

Meal 1 Food / Beverages

Snack Time

Snack Food / Beverages

Meal 2 Time

Meal 2 Food / Beverages (please provide 3-5 examples)

Snack Time

Snack Food / Beverages

Meal 3 Time

Meal 3 Food / Beverages

Snack Time

Snack Food / Beverages

Bedtime

Bedtime Food / Beverages

Please feel free to add any additional notes or points here: