FA Questionnaire

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Dance Fitness Info
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Thank you for participating in the FATattack 6 week Nutrition/Fitness Wellness program. To better prepare for our 6 sessions together please take a few minutes to complete the following questionnaire. After you submit your nutrition history you will be sent to another page to complete your fitness history.
If you have any questions please feel free to contact me at anytime.

Nutrition / Health History

* Indicates required field

Name *

First

Last

Emergency Contact Name *

First

Last

Emergency Phone Number *

Are you pregnant? *

Yes No

Do you smoke? *

Yes No

Are you being treated for any of the following? *

High Cholesterol High Blood Pressure Heart Disease Arthritis Stroke Thyroid Disorder Digestive Problems Shortness of Breath PCOS Asthma (uncontrolled) Diabetes Neurological Disorder/Seizures Cancer Spinal Disorder Muscle or Joint Problems

If you answered YES to 2 or more of the above conditions, did your DR give permission to exercise and participate in weight loss programs? *

Yes No

Do you take vitamins/supplements? *

Yes No

If yes, please list what you take? *

Do you have any food allergies or restrictions? *

Yes No

If yes, please explain. *

What type of menu do you follow on a regular basis? *

I have no food restrictions. I live a Vegetarian Diet Lifestyle I live a Vegan Diet Lifestyle I live a Keto Diet Lifestyle Other:

No restrictions means you eat from all food groups.

If other, please explain: *

What is you biggest struggle with food? *

Pre-Planning and Preparation of Meals Stress/Emotional/Mindless Eating Portion and Calorie Control What are macronutrients? I struggle with ALL of the above.

Choose the item that is your biggest struggle.

What is your 6 week Nutrition Goals? *

Submit

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