Nutrition Questionnaire Name* First Last Date of Birth* Month Day Year Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Gender:* Female Male Other Weight* Height* How did you hear about the Durable Athlete?* Did someone refer you?* Are you currently being treated for a medical condition?* Yes No Prefer not to say If so, what medical condition? List all over the counter or prescription medications you are taking:Vitamin, mineral or other supplements (including probiotics, herbals, botanicals, bioidentical hormones):All allergies or sensitivities:Is there a specific health and wellness factor that brings you to this nutritional consultation today?*What are your primary health and wellness goals and/ or concerns?*What would you like to accomplish regarding your health & wellness short term (1-6 months)?*What would you like to accomplish regarding your health & wellness longer term (6 months-1 year)?*Have you previously utilized nutritional or lifestyle protocols for the betterment of your health and wellness, and if so what were they and what were your results?Are there any obstacles or challenges that you believe may make it difficult to achieve your health and wellness goals?How many meals per day do you eat?* 1 1-2 2 2-3 3+ If you skip meals what meal(s), do you usually skip: Breakfast Lunch Dinner How many days a week do you skip this meal? How many times per week do you eat out, or bring home take-out food?* What is a typical snack?* Do you often feel hungry? Yes No Do you frequently feel thirst?* Yes No What beverage do you drink most in a given day?* Do you eat beyond feeling full?* Yes No What are the foods you eat most frequently?*Are there any foods will you NOT eat?*Describe your typical daily energy level?* Low Mid High What is your current stress level?* Low Mid High What do you think causes you stress?What do you do to relieve stress?How many hours do you sleep per night?* Do you wake feeling rested?* Yes No Do experience any sleep problems?* Getting to sleep Staying asleep Waking in the morning None Do you engage in regular physical exercise?* Yes No Type of Exercise? How often do you exercise? Is there anything else you would like to share?