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Dieting Assessment

General Information

Name

First Last

Phone

Email

Gender

Male

Female

Other

Age

Date of Birth

MM slash DD slash YYYY

Measurements

Weight (kg)

Height (cm)

Waist (cm)

Chest (cm)

Shoulders (cm)

Thigh (cm) - Left

Thigh (cm) - Right

Bicep (cm) - Left

Bicep (cm) - Right

Calf (cm) - Left

Calf (cm) - Right

Questionnaire

Your current diet is best characterized as:

Low Fat

Low Carb

High Protein

Vegan/ Vegetarian

No Special Diet

Other

Blood Type

Please list any food allergies

How would you describe your current activity level?

Sedentary

Moderately Active

Active

Highly Active

How many times do you usually eat in a day?

Do you usually eat in the morning/ have breakfast?

List the foods you enjoy eating

How much water do you drink daily?

How long after starting your diet do you expect to see results?

Do you suffer from diabetes, asthma, high or low blood pressure? If so, please list below. Please specify if you have any other health conditions not mentioned.

Are you currently using chronic medication that may impact your training? If so, please specify.

Do you consume alcohol?

Yes

No

Are you pregnant?

Yes

No

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