LBN Nutrition Analysis

Client's name:(required)

Client's Email: (required)

Gender:(required)
MALEFEMALE

Age:(required)

Date of Birth:(required)

Height:(required)

Weight:(required)

Body fat percentage:(if known)

Blood pressure:(if known)

Given the following goals, please rank them in order of importance,
with 1 being the most important and 8 being the least important.

Improved health:(required)
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Increased muscle mass: (required)
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Improved endurance: (required)
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Fat loss:(required)
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Increased strength:(required)
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Increased power:(required)
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Sport specific*: (required)
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Weight gain: (required)
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*Please provide the sport or athletic event for which you are training: (required)

Do you have a specific timeline for this goal? If so, please specify:

Are you currently exercising at least 3 days a week? (required)

How long have you been consistently exercising without a break? (required)

On a typical week, how often do you lift weights? (required)

When weight lifting, would you say you work with light, moderate, or heavy weights? (required)

On a typical week, how often do you incorporate cardio sessions? (required)

What type of gym or equipment do you have access to? (required)

What type of facilities do you have access to? (basketball courts, a park, pool, field, track, etc) (required)

If you have any diagnosed health problems, list the condition(s):

If you are on any medications, please list them:

If you have any injuries, please list them:

What additional therapies or interventions are being undertaken for the given injury(s)?

What do you do for a living? (required)

What is the activity level at your job? (required)
NONE (SEATED WORK ONLY)MODERATE (LIGHT ACTIVITY SUCH AS WALKING)HIGH (HEAVY LABOUR VERY ACTIVE)

Does your job involve shift work? (required)

If you follow a more regular schedule, do you work days, afternoons, or nights? (required)

What are your stress levels like on a day to day basis? Think both work and home. (required)

If you answered yes to stressed, what are you currently doing to manage this stress?

Do you consume alcohol on a weekly basis? If so, how many servings? (required)

Are you, or have you been a habitual smoker in your life time? (required)

How much water do you consume daily? (required)

Are you a primary caregiver for children, individuals with a disability, or an elder relative? (required)

How often do you travel? (required)
RARELYFEW TIMES A YEARFEW TIMES A MONTHWEEKLY

What are your energy levels like on a day to day basis? (required)

Please list the physical activities you participate in outside of the gym and outside of work: (required)

Please outline a normal daily schedule listing the time you wake up, work and have breaks, work out and go to sleep: (required)

How much money do you spend on groceries per month? (required)

How many times per week do you shop for groceries? (required)

How many meals do you eat in restaurants and/or fast food places per week? (required)

How much money do you spend on supplements per month? (required)

If you have any known food allergies, please list them below:

Are there any other foods to which you are particularly sensitive (I.e., which cause excessive gas, bloating, stuffiness, or congestion)?

How well do you feel your digestion is? (required)

How regular are your bowel movements and do they pass easily? If not, what type of consistency is the stool?

What is your memory and concentration like? (required)

What are your joints like? Do you have any stiffness in the mornings? (required)

If you’re currently using any nutritional supplements, please list them (as well as the doses you’re taking) below:

How long have you been eating in the manner recorded on your dietary
record? (required)

Please provide a 3-day dietary record in the box below. Be sure that these records are representative of the last few months of your dietary intake. In other words, if you just decided to get in shape two weeks ago and changed your diet dramatically, you should give us an indication of how you had been eating habitually prior to the recent change. (required)

If there is any other information you think might be relevant to your program design, please share it with me below.

Do you have trouble falling asleep at night? (required)

Do you have difficulty waking up in the morning? (required)

Do you sleep less than 8-9hrs a night? (required)

Do you wake up once or more during the night? (required)

Do you sleep in a room with any light or noise? (required)

Do you wake up feeling tired? (required)

Do you wake up only with an alarm? (required)

Do you go to bed later than 11pm? (required)

Do you get up earlier than 6am? (required)

Do you use medications (OTC or Rx) for sleep? (required)