Questionnaire

This Questionnaire is great to have as a pre and post diet progress report. Please print it and fill it out so you can see for yourself how much you improve.

Name____________________________________________   Age______     Date_____  

Waist Size______   Weight_______   Body fat %______   Male/Female    Blood type________

 Please answer the following questions by filling in the blank or underlining the correct answer

1. My digestion is sluggish/poor/good
2. I am not/somewhat/very sensitive to foods in general
3. I never/ rarely/often/sometimes get bad stomach aches after eating
4. I never/ rarely/often/sometimes have bad, stinky gas
5. I never/ rarely/often/sometimes am bloated
6. I never/rarely/often/sometimes get diarrhea
7. I go poo 1/2/3/4/5 times per day
8. My daily energy level is ____/10
9. I would love to be ______lbs heavier/lighter
10. I take medication for high blood pressure/diabetes/ulcers/indigestion/chronic pain/depression

 

My main goals with nutrition and health are ;

1.

2.

3.