Nutrition Questionnaire

Please fill in this questionnaire on joining Evolution Outdoors. Our nutrition coach will review it and contact you if we feel we can offer some positive suggestions to create optimal health.

Contact Details

Please fill in your contact details.

Firstname:*
Surname:*
Phone - Mobile:*
Email:*
Date of Birth: Day Month Year
Gender:*
Q 1: Which KLIK (group) do you belong to?

Nutrition

Q 2: Please describe each meal (up to 5), including snacks, that you have in a typical working day? Try to describe portion size and cooking method. Meal 1:
Q 3: Meal 2:
Q 4: Meal 3
Q 5: Meal 4:
Q 6: Meal 5:
Q 7: How much water do you drink per day (in litres)?
Q 8: What drinks do you consume in day (include tea, coffee, sodas, energy drinks, fruit juice etc)?
Q 9: Do you smoke?
Q 10: If yes, how many per day?
Q 11: Describe how much alcohol do you consume in a week?
Q 12: How would you rate your energy levels on a scale of 1-10? (10 being high energy) 1: 2: 3: 4: 5: 6: 7: 8: 9: 10:
Q 13: How would you rate your stress levels on a scale of 1-10? (10 being highly stressed)
Q 14: Do you take a daily vitamin suppliment(s) (e.g. Omega 3, Multivitamin, Glucosamine etc)? If yes, which brand?
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18th May, 2009

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