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Men’s Questionnaire
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2022-12-28T12:36:40+00:00
Men's Nutrition Questionnaire
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Step
1
of
6
16%
Name
*
First
Last
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Date of Birth
MM slash DD slash YYYY
Email
*
Reason for Consultation
Goals
Height
Weight
How many times do you usually eat per day?
Describe 3 full typical day's meals, snacks and drinks, and time of each (please be specific and very complete).
Do you...
Smoke
Drink alcohol
If so, how much and when?
Do you drink caffeine
Yes
No
What kind? How much/when?
Do you ever overeat
Yes
No
If so, which foods and how often?
Do you have any food allergies, restrictions, or sensitivities?
Describe your daily energy levels?
Do you get noticeably irritable, lightheaded, or weak if you haven't eaten in awhile?
Do you crave any of the following? (Please check all that apply)
Sugar
Fried Foods
Milk
Fat
Chocolate
Meat
Pasta
Alcohol
Desserts
Fish
Bread
Other
Select All
Which oils do you use or consume? (Please check all that apply))
Butter
Coconut Oil
Corn Oil
Soybean Oil
Margarine
Hemp Oil
Crisco
Canola Oil
Mayonnaise
Grape Seed Oil
Olive Oil
Peanut Oil
Vegetable Oil
Sun/Safflower Oil
Other
Do you have problems chewing or swallowing?
Yes
No
Do you eat fast?
Yes
No
Is your eating environment peaceful or stressful?
Peaceful
Stressful
How much time do you have for meals?
Personal Questions
How often do you have a bowel movement?
How often do you urinate?
Do you exercise? If so, what kind? How often? Since when?
My daily energy level is...
Poor
Fair
Good
Excellent
My energy level after exercise
Poor
Fair
Good
Excellent
My general enjoyment of life is...
Poor
Fair
Good
Excellent
My dental health is...
Poor
Fair
Good
Excellent
My digestion is...
Poor
Fair
Good
Excellent
My daily stress level is...
None
Low
Moderate
High
Very high
How many hours of sleep do you get on average each night?
Any problems sleeping?
Do you take nutritional supplements or vitamins? If so, which ones? (Please be specific)
Please list any prescription or over the counter medications you take on a regular basis.
Family History: Please list any disease, illness or ailments in your immediate family ( i.e. parents, grandparents, siblings)
Rank your skin without lotion.
Very Dry
Dry
Normal
Oily
Combination
Please check any of the following that pertain to you (past or present):
Acne
Addiction (Alcohol, drugs)
Anemia
Arthritis (Rheumatoid or Osteo)
Anorexia
Anxiety
Bladder Infections
Bloating (gas or indigestion)
Blood Sugar Problems
Bronchitis
Cancer
Colds (frequent)
Cold Sores
Chronic Fatigue
Constipation
Dandruff
Diarrhea
Difficulty losing weight
Difficulty gaining weight
Diabetes 1
Diabetes 2
Diarrhea
Emotional problems
Emphysema
Fainting
Gall bladder problems
Gout
Hair Loss
Headaches
Heart disease
Heartburn
Hemorrhoids
Herpes Simplex
High blood pressure
High cholesterol
HIV
Hot Flashes
Hypoglycemia
Insomnia
Intestinal problems
Kidney stones
Liver problems
Loose stools
Memory loss or confusion
Panic Attacks
Parasites
Pregnant/nursing
Respiratory problems
Ringing in ears
Seizures
Severe mood swings
Skin conditions
Stroke
Thyroid conditions
Yeast infections
Please check all that apply:
Frequent urination
Difficulty urinating
Difficulty with Erection
Loss of libido
Prostrate enlargement
Feel free to expand on any concerns that you think are important/relevant to your health.
Comments
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