DG Lifestyle Questionnaire "*" indicates required fields Name* First Last Email* Mobile*Age* Height* Gender* Female Male What are your goals? What do you want to change?*What has made you decide to take action now?Would you prefer nutrition consultations or personal training sessions (with nutrition incorporated)?* Nutrition Personal Training Not sure What time of the day is you first meal and what do you usually eat?*List the different meals/snacks you normally havePlease write down what you would eat mid-mornings (if applicable).What do you usually have for lunches?*What do you have mid afternoon to eat and or drink?*Do you snack after work? If yes, what do you have?*What do you typically have for dinners?*What snacks or treats do you like and when?*Are your weekend food choices much different to your weekday?*What common foods do you NOT eat?How many coffees and other caffeine drinks a day? 0 1 2 3 4+ How many cafe-style milky coffees a day? 0 1 2+ How many glasses of water do you drink a day? 0-2 (up to 500 ml) 2-4 (500 ml to 1 litre) 4-6 (1 litre to 1.5 litres) 6-8 (1.5 litres to 2 litres) Often 2 litres or more What supplements do you take, or have taken in the last year? Do you exercise regularly each week? Yes No This includes golf and other outdoor activities.If you do exercise, write down what you would typically do on each day (and the time of day).Do you use a personal trainer or other exercise professional? Yes No Not currently but have in the past Do you have any injuries or conditions that would make exercise difficult?*What time do you normally wake? Do you usually wake refreshed or tired? Generally sleep well, wake refreshed Generally sleep well but wake tired Struggle to sleep for 7-8 hours Wake for extended periods most nights What time do you usually turn your lights/devices off to sleep? Are you stressed at present or recently? Yes No How many times would you get sick in a year? 0 -1 2 3 + How many nights a week do you drink alcohol? 0 1-2 3-4 5+ How often do you go grocery/supermarket shopping? Hardly go One to two times a week As often as required Do you have a history or is there a family history of any of the following* Diabetes Heart disease High cholesterol High blood pressure Overweight or obesity Other not listed None of the above Do you have any of the following health or lifestyle related conditions? Arthritis Anxiety Chronic pain Dairy sensitivity Depression Eating disorder Excessive alcohol Gluten sensitivity Gout High Stress Irritable bowel Mood swings Psoriasis or Eczema Smoker Other Please check if any of the following apply PCOS Irregular mensturation Painful mensturation Pre-menopause Other female reproductive condition(s) Taking the contraceptive pill Hormone releasing Mirena Non-hormone Mirena What is the heaviest you have weighed and in what year? What is the lightest you have weighed and in what year? Are you allergic to anything? Yes No Please state any known or suspected allergies or food sensitivitiesAny other comments that you feel may be relevant?Last question; how did you hear about Dean GeddesPhoneThis field is for validation purposes and should be left unchanged.
