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.

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