Health & Nutrition Questionnaire

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JayTrain Lifestyle

Health & Nutrition Questionnaire

Please fill out this questionnaire honestly. The answers will be sent to Coach Jay to prepare a personalized strategy.

1. General information

First & Last Name *

Age *

Gender

Email Address *

Phone Number

Size *

Current weight *

Goal weight *

Goals *Weight lossMass gainRecompositionOther

Secondary goals

2. Medical history & health

Diabetes/ insulin resistanceHormonal problemsHeart problems / hypertensionHigh cholesterolDigestive disordersAllergies / intolerancesInjuries / limitationsOthers

Current medications

Major surgeries

Menstrual cycle

Symptômes hormonaux

3. Lifestyle habits

Sleep / night

Sleep quality /10

Stress /10

Alcohol

Tabac

Caffeine

Hydratation

4. Santé mentale & bien-être

Depression or anxietyPsychologist/psychiatrist consultationSad moodIrritabilityAnxiety

Emotional well-being /10

Influence on food

5. Activité physique

Current activity

Types / fréquence

Depuis combien de temps?

Blessures / douleurs

GymHomeOutsideLowModerateHigh

6. Habitudes alimentaires

Number of meals / day

Particular times

Repas simples ou élaborés

Do you like cooking?

Food budget

Restaurant / prepared dishes

Plat réconfortant

Chaud ou froid?

Tend to snackSweet cravingsSalty cravings

7. Metabolism & motivation

Insulin resistance?

Family history

Energy during the day

Weight changes

Difficulty losing weight?

Why now?

Main obstacles

Engagement /10

Highly structuredFlexible

8. Préférences alimentaires

Coche Oui si tu aimes, Non si tu ne veux pas dans ton plan.

Fruit 🍇

AppleYesNo

PearYesNo

BananeYesNo

OrangeYesNo

BlueberriesYesNo

GrapeYesNo

PeachYesNo

CherryYesNo

KiwiYesNo

AnanasYesNo

FramboiseYesNo

MangueYesNo

NectarineYesNo

StrawberryYesNo

WatermelonYesNo

Vegetables 🥦

BroccoliYesNo

CauliflowerYesNo

SpinachYesNo

AsparagusYesNo

KaleYesNo

CourgetteYesNo

LettuceYesNo

CarrotYesNo

ChampignonYesNo

AubergineYesNo

TomatoYesNo

CucumberYesNo

CeleryYesNo

OnionYesNo

GarlicYesNo

Protein 🍗

ChickenYesNo

BirdYesNo

Lean beefYesNo

Lean porkYesNo

AgneauYesNo

Poisson blancYesNo

SaumonYesNo

ThonYesNo

ShrimpsYesNo

CrabeYesNo

HomardYesNo

ThonYesNo

Carbohydrates / Starches 🍚

Riz brunYesNo

Riz basmatiYesNo

QuinoaYesNo

Pâtes complètesYesNo

Pâtes sans glutenYesNo

Pommes de terreYesNo

AvoineYesNo

Pain completYesNo

LégumineusesYesNo

CouscousYesNo

OrgeYesNo

MilletYesNo

Milk products 🥛

Lait de vacheYesNo

Lait d’amandeYesNo

Lait de soyaYesNo

Lait d’avoineYesNo

Yogourt natureYesNo

Yogourt grecYesNo

Fromage allégéYesNo

Fromage cottageYesNo

Good fats 🥑

AvocatYesNo

Huile d’oliveYesNo

Huile de cocoYesNo

Beurre d’amandeYesNo

Beurre de cacahuète naturelYesNo

Graines de chiaYesNo

Graines de linYesNo

Graines de citrouilleYesNo

AmandesYesNo

Noix de cajouYesNo

Noix de GrenobleYesNo

Important : ce formulaire ne remplace pas un avis médical.

Destination : coachjay@jaytrain.ca

Let’s start gym training now

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