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:*	Please Select Male" Female"

Q 1: Which KLIK (group) do you belong to?

Please select -------------------- Balmain - SYD - Julia Challenor Balmoral - SYD - Rod Cotty Bondi - SYD - Aaron Laurence Bronte - SYD - Matt Buckland Cammeray - SYD Coogee - SYD - Jayne McPherson Maroubra - SYD - Maciek Queens Park - SYD - Samantha Hannaford Rozelle - SYD - Cameron Gerrie Rushcutters - SYD - Rob Meneses Paddington - BRIS - Amy Bridle

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)?

Please select -------------------- <0.5 Ltrs 0.5-1 Ltrs 1-1.5 Ltrs 1.5-2 Ltrs 2-2.5 Ltrs 2.5+ Ltrs

Q 8: What drinks do you consume in day (include tea, coffee, sodas, energy drinks, fruit juice etc)?

Q 9: Do you smoke?

Please select -------------------- Yes No

Q 10: If yes, how many per day?

Please select -------------------- 1-5 6-10 11-15 16-20 20+

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:

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10:

Q 13: How would you rate your stress levels on a scale of 1-10? (10 being highly stressed)

Please select -------------------- 1 - Never stressed 2 3 4 5 6 7 8 9 10 - 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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