Dietary questionnaire

Name: *

Email *

Date of birth: *

Sex: *

Phone number: *

Height: *

Weight: *

Waist circumference: *

Hip circumference: *

Expected Body Weight: *

Please tick the answers you want *

Weight loss
Weight gain
Improvement of health condition
Prevention
I have questions
Healthy eating
Muscle building

Type of work performed: *

Time spent per day sleeping, working and relaxing: *

Leisure activities: *

Sports/exercises practiced: *

Smoking (how much, how long): *

Drinking alcohol (how much, how often): *

Current mood: *

(diabetes, atherosclerosis, anemia, hyperlipidemia, hypertension, depression, reflux, ulcers, stones, psoriasis, migraine, cancer, hypothyroidism/hyperthyroidism, Hashimoto's, insomnia, gout, obesity, osteoporosis, irritable bowel syndrome, celiac disease)

Current: *

In the past: (childhood obesity, anorexia, bulimia?): *

Illnesses in family: *

Family - are there weight problems? *

Are you under regular medical care? If yes, please list specialties and specify frequency of visits: *

Medications taken (name of medication, dosage, time of day taken):

Dietary supplements taken (name of supplement, dosage, time of day taken):

(constipation, diarrhea, vomiting (provoking vomiting), heartburn, nausea, abdominal/stomach pain, swallowing problems, chewing problems, anorexia, decreased/increased food intake, appetite changes)

Current: *

Past: *

Food allergies, intolerances, hypersensitivities, protein diathesis: *

How often do you have bowel movements? *

Do you use pharmacological contraception?

Are you pregnant?

Are you postpartum?

Are you breastfeeding?

Are you planning to get pregnant soon?

Do you have regular periods?

Do you have PMS or pain during your periods?

Do you experience appetite changes before your period?

Number of meals per day: *

How much water you drink during the day: *

Vegetables and fruits per day: *

4-5 servings per day
2-3 servings per day
1 portion a day
very rarely

Frequency of meat consumption: *

daily
4-5 times a week
2-3x a week
once in a while
not at all

Frequency of fish consumption: *

daily
4-5 times a week
2-3x a week
once in a while
not at all

Most common way of preparing food: *

cooking
stewing
grilling
baked
fried

Frequency of consumption of milk and dairy products: *

more than 2x a day
1-2 times a day
rarely
not at all

Most frequently consumed milk and milk products: *

Standard fat
low-fat
fat-free

Frequency of consumption of whole grain products and groats: *

4-5x daily
2-3x daily
rarely
Not at all

Frequency of consumption of pulses: *

daily
4-5x a week
2-3x a week
rarely
not at all

Does snacking occur? *

Coffee/tea (how often, in what amounts, with what additives): *

What do you like to eat and what do you dislike? *

Which products should definitely appear on the menu and which should not? *

List your favorite foods/products: *

List your disliked foods/products: *

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