‘If my mind can conceive it,

and my heart can believe it

-then I can achieve it.’

Muhammad Ali

Disclaimer

Please read this document carefully. If you agree to these terms, please enter your name in block capitals, sign and date at the bottom of the page.

Nutritional Questionnaire

I certify that all the information I have provided in the nutrition questionnaire is accurate and complete to the best of my knowledge as of the date of my signature below. I agree to accept responsibility for omissions regarding my failure to disclose any past or currently existing health/medical conditions.

Medical Advise

Gordon Greenhorn only provides general nutritional health information, and should be used for informational purposes only. Gordon Greenhorn does not provide any medical diagnoses, symptom assessments, health counselling or medical opinions for individual clients.

Copyright

I acknowledge that information provided to me is for my information only and is copyright of Gordon Greenhorn. I agree that I shall not share, post, copy or distribute the information on any form of media or share with any individuals. I accept that there are no refunds for any reason.

Liability

I acknowledge that Gordon Greenhorn is not responsible for any liability, claims, demands, losses, costs, damages, expenses, actions, causes of action, suits, or other proceedings by whomever made, sustained, brought or prosecuted in any manner based upon, occasioned by or attributable to my use of the information provided by Gordon Greenhorn.

Name
Sign
Date

Personal Details

Name
Age
Location
Occupation
Height (cm)
Weight (Kg)

Medical History

Please indicate whether you or a member of your immediate family has suffered from;

You () / Immediate Family Member ()
Coronary Heart Disease
Congenital Heart Disease
Heart Murmur
Angina (Chest Pain)
Heart Attack
High Blood Pressure
Stroke
Diabetes (Type I/ Type II)
Epilepsy
Cancer (Type)
Stomach Ulcers
Lung Disease
Asthma/Emphysema
Osteoporosis
Hernia
Kidney Disease
Migraines
Eating Disorder

Do you smoke?


Yes
No
Ex-smoker

If so, please indicate duration and frequency?

How many years have/did you smoked for?
How many cigarettes/cigars do/did you smoke per day?

Are you pregnant?


Yes
No

Current physical activity level

Please indicate which types of exercise you regularly undertake, by ticking the relevant box:

WalkingRunningSwimmingCycling

YogaPilatesRacquet SportsWeight lifting

Net SportsOther (Please specify) ______

Daily energy expenditure

Please complete this energy diary for one day; typically this would be a day during the week.

  1. Fill out the table hour by hour, by noting minutes spend in each activity zone
  1. Example: if you wake up at 7.30 AM and starts walking around in your home until 8.00 AM you would enter “30 min” under “Sleeping” and “30 min” under “Standing / walking” in the line starting with “7:00”
  1. After filling out the entire 24 hours, you can sum up minutes in the “Sum” line. Recalculate minutes into hours and minutes in the bottom line.

Time of Day / Sleeping / Sitting / Standing/
Walking / Light Exercise / Moderate Exercise / Intense Exercise
24:00-01:00
01:00-02:00
02:00-03:00
03:00-04:00
04:00-05:00
05:00-06:00
06:00-07:00
07:00-08:00
08:00-09:00
09:00-10:00
10:00-11:00
11:00-12:00
12:00-13:00
13:00-14:00
14:00-15:00
15:00-16:00
16:00-17:00
17:00-18:00
18:00-19:00
19:00-20:00
20:00-21:00
21:00-22:00
22:00-23:00
23:00-23:59
Sum
Recalculate hours: minutes

Self-Evaluation

Please indicate which level best describes you, by ticking the relevant box:

Level A

Level B

Level C

Meal Frequency

On your new plan, would you prefer smaller more frequent meals? Or larger, less frequent meals? Please explain your preference.

Body Type

Please indicate which of the following body type’s best describes you, by ticking the relevant box:

Ectomorph MesomorphEndomorph

  • Fragile
  • Thin
  • Flat chest
  • Delicate build
  • Young appearance
  • Tall
  • Lightly muscled
  • Stoop-shouldered
  • Large brain
  • Has trouble gaining weight
  • Muscle growth takes longer

Nutritional Survey

Please indicate the frequency of your nutritional intake,using the following key:

Habitually- On a daily basis

Often- Roughly 3 times per week

Occasionally- Roughly once per week

Rarely- Roughly 2 times per month

Never- Complete avoidance

Habitually / Often / Occasionally / Rarely / Never
Drink alcohol
Eat in restaurants
Eat fast food
Pastries, cookies, sweets, junk food
Add sugar to tea, coffee or other food
Fizzy drinks
Instant breakfasts (pop tarts, muffins, doughnuts)
Deep fried foods
Margarine
Meat (beef, lamb, pork)
Chicken or turkey
Fresh fish
Processed meat (sausages, burgers)
Fresh fruit
Fresh vegetables
Salads
Wholegrain foods (brown bread etc.)
White flour products (white bread, rolls etc.)
Beans
Yogurt
Milk
Cheese
Eggs
Salt
Water consumption (how often per day)
Eat if bored or depressed
Swallow food before chewing well
Hurried or rushed meals
Stuff yourself
Read/understand food labels
Sneak or hide foods

Nutritional Goals

Please use the following section to describe your personal nutritional goals:

 / Comments
To gain lean mass
To lose weight
To improve sports performance
To achieve a healthy diet
Other (please specify)

What are the reasons behind your personal nutritional goals?

When would you like to achieve your personal nutritional goals?

Have you previously tried to achieve these goals in the past?


Yes
No

If so, how successful were you at achieving your personal nutritional goals?

And what challenges did you encounter when attempting to achieveyour personal nutritional goals?

Please indicate any instances or situations which may prevent you from achieving your goals?

How motivated are you to achieve your nutritional goals? Using the following key, please indicate by circling the corresponding number:

1-Not motivated at all

10-Extremely motivated

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10

How knowledgeable about nutrition would you consider yourself?


Not at all
Basic
Moderate
Considerably
Extremely

Food Diary

In order to assess your current nutritional intake, complete the following 3 day food diary.

Please complete in as much detail as possible and include all food and drink consumed for the entire duration, using the following sample as a guide:

Time: / Meal: / Consumption:
7:30am / Breakfast / 150g Greek yoghurt 0% Fat
50g Blueberry’s
1 cup of coffee, black with 1tsp sugar
1 large banana
9:45am / Morning Snack / Kit Kat Chunky
1 cup of coffee, black with 1tsp sugar
11:00am / Mid-morning snack / 4 organic rice cakes
50g peanut butter
1:00pm / Lunch / Large green salad
8 cherry tomatoes
100g sliced cucumber
2 tsps. balsamic vinegar
200g plain grilled chicken breast
125g boiled basmati rice
3:30pm / Afternoon Snack / 1 large Golden Delicious apple
2 rich tea biscuits
250ml freshly squeezed orange juice
6:00pm / Dinner / 1tsp. Olive oil
50g wholemeal spaghetti
Tinned tomatoes
30g low fat grated mozzarella cheese
150g lean beef mince
Sprig of fresh parsley
8:00pm / Evening snack / 150g porridge oats
3 tsp. organic honey
50ml semi-skimmed milk

Day 1

Time: / Meal: / Consumption:

Day 2

Time: / Meal: / Consumption:

Day 3

Time: / Meal: / Consumption:

Nutritional Preferences

In order to produce a suitable nutritional plan, please use the following section to describe your personal preferences:

Please provide a list of foods you dislike, ensuring you include any specific food allergies you have, to allow these to be omitted from your new diet plan?

Please provide a list of healthy foods that you enjoy?

Do you currently use any sports nutrition products e.g. Creatine, protein powder etc.?


Yes
No

If not, would you consider doing so if it were to assist you in achieving your nutritional goals?


Yes
No

Please describe your sleeping habits, including average nightly duration of sleep and any difficulties faced?

Please include two whole-body photos.

One of your front and one of your back (relaxed, not tensed).

Front:

Back: