KLUBZ FITNESS NUTRITIONAL PROFILE
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| Name: |
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| Age: |
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| E-Mail: |
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| On a scale of 1 – 10, how would you rate your nutrition (1=worst; 10=best) |
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| How many times a day do you usually eat (including snacks)? |
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| Do you skip meals? |
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| Do you eat breakfast? |
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| Do you eat late at night? |
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| How many ounces of water do you consume daily? |
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| How many caffeinated beverages do you consume daily? |
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| How many times a week do you drink alcoholic beverages? |
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| If you currently smoke, how many do you smoke per day? |
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| Do you feel drops in your energy levels throughout the day? |
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| -If yes how many, and around what times? |
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| What do you eat on an average day? (Include all beverages, esp. water) |
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| Breakfast: |
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| Snack: |
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| Lunch: |
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| Snack: |
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| Dinner: |
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| Snack: |
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| Do you know how many calories you eat on average per day? |
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| -If yes, how many? |
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| Are you currently taking a multivitamin or any other food supplements? |
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| -If yes, please list: |
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Besides hunger, what other reason(s) do you eat? (Please check all that apply)
Boredom
Social
Stressed
Tired
Depressed
Happy
Nervous
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| Do you eat to the point of fullness? |
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| Do you eat foods high in fat and sugar? |
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| At work or school, do you usually: |
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| How many times a week do you usually eat out on average? |
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| Do you do your own grocery shopping? |
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| Do you do your own cooking? |
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| List in order of priority, 3 areas of your Nutrition you would like to improve on? |
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| 1. |
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| 2. |
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| 3. |
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| Ideally, how many pounds would you like to lose? |
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| Are you more interested in private home training or gym training? |
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