Supreme Nutriment - Nutrition Questionnaire

SUPREME NUTRIMENT

Personalised Nutrition Questionnaire

Section 1: Personal Information

Full Name Date of Birth Gender Height Weight Phone Number Email

Section 2: Medical History

Diagnosed With (check or write): Current Medications Allergies / Intolerances Weight-related or Digestive Surgeries

Section 3: Lifestyle & Habits

Occupation Activity Level Average Sleep (hrs) Stress Level Main Sources of Stress Do You Drink Alcohol? Do You Smoke/Vape? Meals Per Day Do You Skip Meals?

Section 4: Nutrition & Eating Habits

Rate Your Diet (1–10) Specific Diet Followed Do You Track Calories or Macros? Method/App Used Time of Last Daily Meal

Section 5: Food Preferences

Favourite Healthy Foods Favourite Treat/Comfort Foods Foods to Avoid Dietary Restrictions (Cultural/Religious) Meal Prep Preference Preferred Number of Meals Per Day

Section 6: Fitness & Physical Activity

Days of Exercise Per Week Types of Exercise Workout Duration Access to Equipment/Gym Fitness Level Injuries or Limitations Fitness Goals Preferred Activities Interested in Custom Workout Plan?

Section 7: Goals & Motivation

Primary Goals Target Weight/Body Composition Biggest Challenges Previous Programs Tried Motivation Level (1–10) What Does Success Look Like?

Section 8: Readiness & Support

Ready to Begin? Preferred Coaching Format Willing to Work With: Do You Have a Support System?

Section 9: Final Thoughts

Anything Else to Share

Supreme Nutriment | Empowering Better Health Through Nutrition & Movement

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Nutrition form

SUPREME NUTRIMENT

Personalised Nutrition Questionnaire

Section 1: Personal Information

Section 2: Medical History

Section 3: Lifestyle & Habits

Section 4: Nutrition & Eating Habits

Section 5: Food Preferences

Section 6: Fitness & Physical Activity

Section 7: Goals & Motivation

Section 8: Readiness & Support

Section 9: Final Thoughts

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