Client Questionnaire

Client Information

Full Name:

Address:

Date of Birth:

Email:

Phone Number:

Occupation:

What is your GOAL with this program (please be specific):

Body Metrics

Current Weight (morning, on empty stomach):

Pounds

Height:

Feet

ㅤ

Inches

Waist measurement (measured at a belly button):

Hip measurement (measured at the widest part):

Nutrition & Eating Habits

How many MEALS and SNACKS do you usually eat per day?

Meals

ㅤ

Snacks

Do you skip meals?

Yes

No

Sometimes

What time do you typically have your first and last meals of the day?

What do you usually drink throughout the day?

Do you follow any specific dietary style (e.g., Mediterranean, Keto, Vegan)?

How often do you eat out per week?

Do you often eat/snack after dinner?

What do you feel might have led to your weight gain?

What has worked or not worked for you in the past when trying to lose weight?

Are there foods you absolutely refuse to eat?

Lifestyle & Habits

Describe your current workout routine:

How many hours do you typically sleep at night?

Do you smoke?

Yes

No

Sometimes

Do you drink alcohol?

Yes

No

Sometimes

If yes, how often and how much?

Have you been diagnosed with any vitamin or mineral deficiencies (e.g., iron, B12, vitamin D)?

Health Screening (Yes/No)

Please indicate if you’ve been diagnosed with or are currently experiencing:

If you answered yes to any of the above questions, please explain it here.

Please select your stool type from chart below:

Describe what your typical day looks like:

Please share any additional information that might be helpful for me to know:

IMPORTANT — Along with this questionnaire, please also submit a 5-day food log (3 weekdays + 2 weekend days).

Step-by-step instructions:

1. Take pictures throughout the day

• Photograph everything you eat and drink (except water).

• Take photos as you go, right before eating or drinking.

2. Add brief descriptions if needed

• If something isn’t clear in the photo, include a short description (e.g., ingredients, portion size, preparation method).

3. Send your log daily

• At the end of each day, email your photos to thefitnutrition@mail.com or text them to 405−562−0425.

4. Repeat for 5 days

• Please complete this for 3 weekdays and 2 weekend days to help provide an accurate overview of your eating habits.

Note:

If this feels like too much work, you may instead submit logs for 1 weekday and 1 weekend day.