Nutritional Profile
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Nutrition and Weight Profile


By filling out this survey, you are not in any way obligated to use our services. This survey will give us enough information to help you through email should you choose to participate in that way. Since we get many request, only general advice will be given and should be reviewed by your doctor before used. Should you be interested in a more in depth assessment, including but not limited to, meal plans, exercise advice, supplement recommendations, specific workout routines and other needs, I can do a full assessment for you at nominal charge $50, my normal 60 minute consult fee. This includes a full client portfolio packed with specific information to get you on your way. You will also receive an account number and my direct access on-line email to answer your specific questions fast. I have proven success working with clients this way. If you are interested send us an email at Remote@buildingahealthybody.com
     
 
 
                                                 
     
Nutrition and Weight Profile Survey
  
   
 
The following survey will be reviewed by Karen Iverson. False or incomplete data will not help you. If you want an accurate assessment, complete the survey in full with accurate data.

Name
Email
Phone  #
  Height
  Age
 years
  Current Weight
 lbs
  Desired Weight
 lbs

If you are trying to lose weight:
What is the most you have weighed as an adult? lbs
What is the least you have weighed as an adult? lbs
How long did you maintain this weight?
What is the lowest weight you maintained for 1 year? lbs
How many times have you lost and regained weight?
What types of diets have you tried?
If you have/had high blood pressure, what weight where you? lbs
Do you have parents or siblings who are overweight?   
Is this a good time in your life to commit to a weight loss program?   
What obstacles are in the way of achieving your goals?
Which do you eat regularly?
How often do you eat out each week?
What size portion do you normally have?
              
How often do you eat more than one serving?
           
How long does it usually take you to eat a meal? minutes
Do you eat while doing activities (eg: reading, work, TV)?   
How many times a week do you eat or drink the following?
Cookies, Cake, Pie    Candy   
Doughnuts    Ice Cream   
Commercial Muffins    Soft Drinks   
Potato Chips    Fried Foods   
Peanut Butter, Nuts, Seeds    Fast Foods   
Cheese    Whole Milk, Cream, Non-Dairy Creamer   
Red Meat (Beef, Pork, Lamb)    Refined Grains (White Rice, Breads) vs Whole Grain   
Bacon, Sausage, Hotdog, Salami    Convenience Items (Frozen Foods, Instant Products, Canned Soup/Food)   
Butter, Margarine, Mayonnaise    More than 1 serving of alcohol/day (4oz Wine, 1.5oz Liquor, 12oz Beer)   
    More than 2 servings of caffeinated beverages in a day   
How many servings of the following foods do you eat each day?
Fruits (1 small whole, or 1/2 cup)    Vegetables (1/2 cup)   
Bread (1 slice)    Cereal (1/2 cup)   
Pasta, Rice, Other Grains (1/2 cup)    Meat (3oz)   
Dried Beans, Peas, Tofu, etc. (1/2 cup)