Health and Lifestyle Survey

Document sleep, hydration, caffeine, alcohol, exercise, work stress and meal timing alongside current and target weight. Nutritionists and wellness coaches use it as an opening history before designing a plan. Sections are separated so answering stays quick.

Use this template

Full name

Nombre

Apellido

Date

Phone number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Preferred contact channels

Email Phone call Text message WhatsApp

Date of birth

Age

Gender

Do you have any of these conditions?

Diabetes High blood pressure High cholesterol Thyroid disorder Heart disease None of these

Do you take medication for any of these?

Are you pregnant?

Yes No Not applicable

Are you breastfeeding?

Yes No Not applicable

Do you have any food allergies?

Yes No

Please describe them

Height

Weight

No image

What is your current body mass index?

Which body mass index do you want to maintain?

What time do you usually go to bed?

What time do you usually wake up?

On average, how many hours do you sleep?

Do you wake up feeling rested?

Yes Sometimes No

How is the quality of your sleep?

How much water do you drink a day?

How much coffee do you drink a day?

How much alcohol do you drink in a week?

How many times a week do you exercise?

What kind of exercise do you do?

Are there things you would like to do but cannot right now?

What is your job?

Do you enjoy your work?

Are there other sources of stress in your life?

What time do you have your first meal?

What time do you have your last meal?

How many meals do you eat a day?

Do you snack between meals? If so, what do you have?

How often do you eat out in a week?

Where do you usually eat out?

Current weight

Target weight

Height

Have you tried to lose weight before?

Yes No

What did you find hardest when trying to lose weight?

Do you smoke?

Yes I quit No

Do you do any exercise?

Yes, regularly Occasionally No

How many hours do you sleep?

Fewer than 5 hours 5 to 6 hours 7 to 8 hours 9 hours or more

Lifestyle summary: this section is completed by the practitioner after reviewing the answers.

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