Dietary Survey

The information that you provide on the this health questionnaire will help me understand your past and present state of health and allow me to design a diet program to better suit your needs.  All information provided will be held in the strictest confidence and will be used by Yoga Belly, LLC only to educate me on the best possible nutrition to fuel my body.

First Name Last Name
Best Email Phone
Date of Birth / /
Height Weight
What is your weight history? Any recent weight gain or loss?
Do you have a particular diagnosis that makes you want to change your diet?
Do you suffer from any of the following issues?
  • Asthma
  • Bruise Easily
  • Joint Pain
  • Headaches
  • Dry Mouth
  • Water Retention
  • Watery Eyes
  • Bloating
  • Skin Rash
  • Memory Issues
  • Brain Fog
  • Fatigue
  • None - I'm super healthy!
Are you currently taking any medications you'd like me to be aware of?
Are you currently taking any supplements or vitamins?
Have you had any recent abnormal labs or other test results?
Are you now or have you recently used any alternative treatments or therapies?
What are your favorite foods?
What foods do you dislike?
Do you have any food allergies?
Do you have any other allergies?
How much cooking do you do?
  • I cook mostly for myself
  • I cook for myself and my family
  • I don't cook very often
How many 8oz glasses of water do you drink per day? Monthly Food Budget $
Do you currently exercise?
  • No
  • Yes
If you do exercise, what do you do and how often?
I understand that this program will give me the basic information to succeed, but that I will be responsible for making the positive changes required. I am not looking for a quick fix, but rather a deeper understanding of what my body needs and doesn't need, and how much of an impact nutrition can make. I commit to being open minded, and approaching this program with a positive mindset.

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