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Green Leaves

Healthy is an outfit
                       that looks different on Everyone

HEALTH & LIFESTYLE QUESTIONNAIRE

We will start with a few simple questions to help your coach determine your nutrition plan. In some situations, your coach may recommend you speak with your healthcare provider before continuing.


BASIC HEALTH INFORMATION

Birthday
Month
Day
Year
Height: Feet
Height: Inches
How would you rate your health?
Gender at Birth?
Male
Female
Are you pregnant?
Yes
No
Are you taking Prenatal Vitamins?
Yes
No
Looking to become pregnant in next 6 months?
Yes
No
Currently Breastfeeding?
Yes
No

HEALTH CONSIDERATIONS

Do you have any of the following?
Do you have any of the following?
Multi-Vitamin
Yes
No
Steroid
Yes
No
Diuretic
Yes
No
Lithium
Yes
No
Hormone Replacement
Yes
No
Weight Loss Medication
Yes
No

WEIGHT + GOALS

What are you looking to gain from your coach?

FOOD + WATER

EATING HABITS

DRINKING HABITS

Have you consumed alcohol in the last 30 days?

SLEEP & STRESS

Rate Your Quality of Sleep
Rate Your Level of Stress

ACTIVITY LEVEL

Have you been advised by a healthcare professional not to exercise?
Describe your current level of activity
Rarely/Never
1-2 times per week
3-4 times per week
5+ times per week
How many minutes do you exercise weekly?
< 30 minutes
30-60 minutes
60-90 minutes
90-120 minutes
120-150 minutes
150+ minutes
In general, how intense are your workouts?
1- Low Intensity
2
3
4
5- High Intensity

Thank you for completing your Health and Lifestyle Questionnaire!

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© 2024 by TANA Lifestyle LLC

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This program and supplements are not intended to diagnose, treat, cure, or prevent any disease. Always check with your physician before starting a new dietary supplement program.

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