Nutrition Questionnaire

1Contact Info

2Your Goals and Challenges

3Basic Information

4Diet

5Exercise and Stress Management

6Doctor Notification Preference

Survey date
MM slash DD slash YYYY
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Survey Date
MM slash DD slash YYYY
First name
Last name
Email*
Cell phone
Home phone
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Best time to reach you
Please indicate the best days and times to do your nutrition consult with Betsy. We'll contact you to schedule a time from there.
Address 1
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Address 2
City
State
Zip Code
Who referred you to Sunshine Wellness (Betsy Markle RD)?

Age
Occupation
Marital status
How many children do you have?
If you have children under 18, please list their ages and names.
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Do you have children under the age of 18?
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Please fill in one row for each child
First Name Age Gender
What is your height?
Feet Inches
What is your current weight?
Please describe your weight history
Please include details about regular and/or occasional fluctuations as well as information about weight loss or gain milestones

Do you exercise on a regular basis?
What is your typical weekly exercise routine? Please include types of exercise, duration and how many times per week.
If it is easier, you can just write out your exercise plan.
Do you consider your life to be stressful?
Describe your sources of stress?
Do you handle your stress well?
What techniques do you use to manage your stress?
Do you get 7-8 hours of uninterrupted sleep per night?
What prevents you from getting that much sleep?
Is there anything else we should know before we get started?

Realistic Nutrition

First Name	Age	Gender