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Weight Loss Specialist in women 35+
Medical Doctor | Msc Nutr | PT
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WHEN OTHER METHODS DON`T WORK
Questionnaire
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Name
*
First
Last
Email
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Phone number (with country code)
Gender
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Female
Male
Date of birth
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Where do you live? (country, city)
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What is your occupation?
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Height (in cm)
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Weight (in kg)
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Waist and hips circumferences in cm
What is your main problem you would like to solve? Or goal you would like to reach?
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Your disorder story
Do you have any chronic diseases, if yes then which ones?
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Have you had any operations, injuries, serious acute conditions?
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Point out if you are in special conditions at the moment, such as pregnancy and breastfeeding ?
WOMEN
Did you give a birth, and how many times if yes?
WOMEN
What supplements do you take constantly? (name, dose)
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Do you take any medicine constantly? If yes please write the name and dose
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Do you have an allergy for any foods or supplements?
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Do you smoke (constantly)?
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How much water approximately do you drink a day?
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How many times a day do you eat?
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How many times a day would you prefer to eat?
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3
3-4
4
4-5
5
5-6
Write down here everything you ate yesterday or other usual day (time, what exactly, amount)
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What is your meal style mainly? (I cook,my wife/husband/partner cook, I eat at the restaurants etc.)
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What is very hard to refuse for you? (for example - sugar, sweets, sausage, beer and so on)
Do you do any sports? If yes - what exacltly and how many times a week?
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Describe your usual day plan (waking up time, work, going to bed time etc.)
If there are any blood tests or other examinations you have , send them on WhatsApp, either bring for a consultation if it`s in person
I will
I have no any
What do you prefer for breakfast? (carbs part)
Oats
Flakes
Muesli
Bread
Crispbread
Buckwheat
Pasta
Potato
Pancakes
Casserole
Fruits, berries
Additionally from carbs I prefer for breakfast/ some particular foods:
What do you prefer for breakfast? (protein part)
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Eggs
Cheese
Cottage cheese
Milk
Yogurt
Protein powder in shake
Fish
Chicken and other poultry
Red meat (pork/beef)
Soya foods
Tofu
Additionally from proteins I prefer for breakfast/ some particular foods:
What do you prefer for second breakfast/snack? (If you chose 3 meals a day, no need to fill up this graph)
Fruits
Berries
Nuts
Seeds
Vegetables
Sandwich (bread and cheese)
Sandwich (bread and meat/poultry/fish)
Yogurt
Milk
Cheese
Usually I don`t do this meal
Additionally I prefer for second breakfast/ some particular foods:
What do you prefer for lunch? (carbs part)
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Rice
Pasta
Potato
Lentils
Beans
Buckwheat
Barley
Millet
Quinoa
Spelt
Oats
Bread
Additionally from carbs I prefer for lunch/ some particular foods:
What do you prefer for lunch? (protein part)
*
Red meat (pork/beef etc.)
Chicken and other poultry
Fish
Eggs
Seafood
Soya foods
Tofu
Nuts, seeds
Additionally from proteins I prefer for lunch/ some particular foods:
What do you prefer for afternoon snack/ potluck lunch? (If you chose 3 meals a day, no need to fill up this graph)
*
Sandwich (bread and cheese)
Sandwich (bread and meat/poultry/fish)
Muesli with milk
Muesli with yogurt
Fruits
Berries
Vegetables
Cheese
Milk
Yogurt
Toast with peanut butter/ humus
Usually I don`t do this meal
Additionally I prefer for afternoon snack/ some particular foods:
What do you prefer for dinner? (protein part)
*
Chicken and other poultry
Fish
Eggs
Seafood
Soya
Tofu
Cheese
Cottage cheese
Protein powder in shake
Additionally from proteins I prefer for dinner/ some particular foods:
What do you prefer for dinner? (carbs part)
*
Bread
Crispbread
Buckwheat
Pasta
Potato
Vegatables
Additionally from carbs I prefer for dinner/ some particular foods:
Which source did you hear about me from?
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