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ABOUT
NUTRITION PLANS
1. Weight Management
2-Fitness Nutrition
3-Busy Professionals
4-Adults 40 & Above
CONTACT
Questionnaires
QUESTIONNAIRE 2
Item
Item
HOME
ABOUT
NUTRITION PLANS
1. Weight Management
2-Fitness Nutrition
3-Busy Professionals
4-Adults 40 & Above
CONTACT
Questionnaires
QUESTIONNAIRE 2
HOME
ABOUT
NUTRITION PLANS
1. Weight Management
2-Fitness Nutrition
3-Busy Professionals
4-Adults 40 & Above
CONTACT
Questionnaires
QUESTIONNAIRE 2
Item
HEALTH & FITNESS QUESTIONNAIRE
LEVEL 1: ALL PATIENTS (5 MINUTES)
PERSONAL INFORMATION
First Name *
Last Name *
Date of Birth *
Age *
Address *
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Country*
Select Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Qatar
Réunion
Romania
Russia
Rwanda
Saint Bartelemey
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islanoption
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Phone *
Email *
Occupation
Married/Single *
Married/Single
Married
Single
People in Household *
Part 2-MOTIVE FOR YOUR CONSULT
What brings you to MaqNutrition today? *
What are your 3 Main objectives? *
What are your expectations from these sessions *
Part 3- General Health
Medical diagnosis (if any) *
Surgeries *
Medications *
Supplements *
Allergies *
Hospitalizations *
Part 4-Lifestyle
Average sleep hours *
0
1
2
3
4
5
6
7
8
9
10
Hours
Hours
Stress Level (Aprox.) *
0
1
2
3
4
5
6
7
8
9
10
Low stress
Very stressfull
Physical activity *
Do you consume alcohol *
Tobacco *
Part 5- Nutrition
Dietary Restrictions *
Favorite Meals *
Foods you avoid *
Who Cooks *
Meal times *
Submit
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