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Nutrition Questionaire

Birthday

Dietary Habits

How many meals do you typically eat per day?
1
2
3
4+
Do you have any regular snacks?
No
Yes
How often do you eat breakfast?
Daily
Occasionally
Rarely
Never
Do you eat out or order takeout frequently?
No
Yes
How much water do you drink daily?
None
Upto 1 litre
1-2 litres
3+ litres

Dietary Preferences and Restrictions

Do you follow any specific diet or eating pattern?
Vegetarian
Vegan
Paleo
Keto
Gluten-free
Other
Do you have any food allergies or intolerances?
No
Yes
Do you drink coffee?
No
Yes
Are there any foods you dislike or avoid?
No
Yes
Do you consume alcohol?
No
Yes
Do you use any dietary supplements (vitamins, minerals, protein powders, etc.)?
No
Yes

Health and Lifestyle

Do you have any medical conditions that affect your diet?
No
Yes
Do you have any digestive issues (e.g., bloating, constipation)?
No
Yes
How would you rate your current energy levels?
Very high
High
Average
Low
Very low
Do you exercise regularly?
No
Yes
How many hours of sleep do you get per night?
Less the 5
5-6
7-8
8+

Goals and Motivation

What are your primary health goals? (Check all that apply)
On a scale of 1-10, how motivated are you to achieve these goals?
1-2 (very low)
3-4
5-6
7-8
9-10 (very high)
What do you believe are the biggest challenges to achieving your health goals?
Lack of knowledge
Time management
Cravings/ emotional eating
Social events
Other
Have you tried any diets or programs in the past?
No
Yes
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