Fit in 15 Nutrition Counseling Questionnaire

Fit in 15! Nutrition Counseling

Name*

First Last

Phone*

Email*

Truck # (if you want us to contact you via QC messages/reminders)

I will send you a summary and goal list of what we talk about today. How do you prefer me to contact you and send you that info?*

Email
Phone
QualComm

What type of driver are you*

PSD
TNT
Trainer
solo driver
team driver
in-house

In general, what are your goals?*

Check all that apply.

Out of all the above goals, which ones feel the most important/urgent? And why? Do you have a past Hx of trying to reach that goal?*

Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries and do you have any medications, either OTC or RX that interact with your lifestyle?*

Yes
No

List conditions/ diagnoses and meds if applicable

Right now, how would you rank your overall eating, nutrition habits?*

Are there any foods you will not eat because of intolerances or allergies? Are there any foods you will not eat because you dislike them?*

What is a typical day of eating look like for you lately?*

Typical fluids*

How ready, willing, and able are you to change?

How READY are you to change your behaviors and habits?*

How WILLING are you to change your behaviors and habits?*

How ABLE are you to change your behaviors and habits?*

How is your stress and recovery?

On average, how many hours per night do you sleep?*

How do you normally cope with your stress?

Summary of call to review with client

Fill out summary box below, this will guide you in guiding client on what to fill out in SMART goal form

Summary of SMART goal(s) and main benefits of achieving it

Summary of steps to take to reach the goal(s)

Date you would like to achieve goal by