[rev_slider_vc alias=”Nutrition”] DM Training Nutrition Assessment Step 1 of 9 11% General Information1. Name* First Last 2. Email* 3. Phone*4. Sex:*MaleFemale5. Age:*6. Height:*7. Current Body Weight:*8. Lean Body Mass (if known):9. Body Fat % (if known): Goals and Readiness1. I would like to adopt a meal plan today because...*2. My overall health goals are...*3. My target weight is...*Please enter a number from 0 to 500.4. Ideally, I'd like to reach my goals in...*1-3 months3-6 months6-9 months9-12 monthsnone5. The biggest challenge (s) to reaching my nutrition goals are:*6. In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals...*Do you have the ability to cook or prepare food?*YesNoIf you do, how much time do you spend cooking/ preparing meals each day?*0 minutes- 30 minutes30 minutes- 1 hour1 hour -2 hoursDo not have time to cook at homeHave you meal prepped before?*YesNoOn a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/ willingness to do the following:1. Significantly modify your diet* 1 2 3 4 5 2. Keep a record of everything you eat each day* 1 2 3 4 5 3. Modify your lifestyle (ex. Work demands, sleep habits, physical activity)* 1 2 3 4 5 4. Engage in regular exercise/ physical activity* 1 2 3 4 5 MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE1. Please provide the names of medications, supplements and or/ antibiotics you are currently taking. Include dosage and frequencyNameDosageFrequency (daily) 2. Do you have any past/ current injuries, surgeries, or physical limitations that would hinder your ability to perform specific movements or physical exercise?*YesNoIf yes, please indicate here:3. Do you have any allergies or dietary restrictions?*YesNoIf yes, please indicate here: ACTIVE LIFESTYLE ASSESSMENT1. Indicate the types of exercise (s) in which you are currently participating* Stretching/ Yoga Cardio/ Aerobics (walking, jogging, biking, etc) Strength Training (weight training, pilates, some yoga) Sports or leisure Other (specify below) None If other, please indicate here:2. Describe the intensity of a typical training session* Average effort Above average effort Intense effort 3. How long does each exercise session last?* 0 minutes- 30 minutes 30 minutes- 60 minutes 1 hour- 2 hours 4. On average, how many exercise sessions do you participate in per week?* 1-2 sessions per week 3-4 sessions per week 5-6 sessions per week 7+ sessions per week 5. Indicate the time in which you participate in your exercise sessions. Be specific about the type of training and day of the week. (include am & pm)*Type of TrainingDay of weekSession begins (am/pm)Session ends (am/pm) WORKPLACE ASSESSMENT1. Please provide your normal weekly work schedule. If not applicable, input "N/A"*SundayMondayTuesdayWednesdayThursdayFridaySaturday2. Please provide the break/ lunch time (s) you are allotted at work. If none, input "N/A"*Break timeDuration3. Which best describes your work place environment?* 1. Light office work, mostly seated 2. Housework, including shopping, errands 3. Clerical, on feet most of the day doing light work 4. Light construction, or lots of walking 5. Heavy construction, warehousing, moving, etc. What is your daily sleep schedule?4. Please indicate the normal times in which you go to bed and wake up each day. (include naps)*Wake upBedtimeNaps (if any) DIETARY & EATING HABITS ASSESSMENT1. Are you vegetarian/vegan?*NoYes2. Please choose all of the items that you consume 2-5 times on a weekly basis.* Fast Food Restaurant food Vending machine food Cafeteria or buffet food Frozen meals Home-cooked meals Leftovers Beef (hamburger, steak, etc.) Pork (chop, loin, ham, bacon, etc.) Liver Lamb Poultry (chicken, turkey, etc.) Deli meat Fish Shell fish Soy foods Beans Crackers Cookies, cake, muffins Whole grains Fresh/raw vegetables Cooked vegetables Fruit, fresh or frozen Canned vegetables or fruit Margarine Dairy (milk, yogurt, cheese, butter) French Fries Fried meat (chicken, fish) Foods with added sweeteners/sugars Artificial sweeteners Meal replacements 3. Describe in detail a normal breakfast meal you would consume during a typical weekday. Include the breakfast item (s), quantity, and time consumed.*Time consumedItem descriptionQuantity Please list all items4. Describe in detail a normal lunch meal you would consume during a typical weekday. Include the lunch item (s), quantity, and time consumed.*Time consumedItem descriptionQuantity Please list all items5. Describe in detail a normal dinner meal you would consume during a typical weekday. Include the dinner item (s), quantity, and time consumed.*Time consumedItem descriptionQuantity Please list all items6. Describe in detail the snacks you would consume during a typical weekday. Include the snack item (s), quantity, and time consumed.*Time consumedItem descriptionQuantity Please list all items 1. From the following list, select all of the meats in which you consume:* Chicken, with skin Chicken, without skin Turkey, with skin Turkey, without Processed meat (sausage, salami, bologna, hotdogs, etc.) Liver Hamburger Beef Pork Lamb Fish None 2. Identify the types of, breads, potatoes, and rice you consume. (Select all that apply)* White bread, including pita bread Dark bread, including wheat pita French fried potatoes Potatoes, baked, boiled, or mashed Rice or pasta (spaghetti, noodles, etc.) Oil and vinegar dressing (e.g. Italian) Cold Breakfast Cereal None 3. From the following list, select all of the vegetables (fresh or frozen) in which you consume:* Artichokes Asparagus Avacados Beets Bell Peppers Broccoli Brussel sprouts Cabbage Carrots Cauliflower Celery Cucumbers Eggplant Garlic Green beans Greens such as spinach, chard, collard, or kale Leeks Mushrooms Okra Onions Parsnips Peppers Radishes Rutabegas Shallots Spinach Squash of all kinds Sweet potatoes Tomatoes Turnips Yam Zucchini None 4. From the following list, select all of the fruit in which you consume:* Apples Apricots Bananas Blackberries Blueberries Cantaloupe Cherries Cranberries Figs Grapefruits Grapes Kiwi Lemons Mangoes Nectarines Oranges Peaches Pears Pineapple Plums Plutos Pomegranates Prunes Raisins Raspberries Star fruit Strawberries Tangerines Watermelon None 5. From the following list, select all of the snacks in which you consume:* Dark chocolate Candy without chocolate Pie, homemade Pie, ready made Cake Snack cakes (Little Debbie, Hostess, etc.) Cookies Chips Nuts Peanut butter Other None 6. Please list all of the food items that you do NOT like* 1. Please indicate how often you consume water during a normal week*TapFilteredBottled2. Please indicate how often you consume coffee during a normal week*RegularDecafLatte3. Please indicate how often you consume tea during a normal week*UnsweetenedSweetenedHerbal4. Please indicate how often you consume juice during a normal week*NaturalArtificially Flavored Fruit Juice5. Please indicate how often you consume soda during a normal week*RegularDiet6. Please indicate how often you consume milk during a normal week*Whole2%1%Skim7. Please indicate how often you consume milk alternatives during a normal week*Almond MilkSoy Milk8. Please indicate how often you consume alcohol during a normal week.*WineBeerLiquor9. List any other beverages that you consume during a normal week that are not mentioned above Select Meal Plan*FREE Nutritional Information7-Day Meal Plan14-Day Meal Plan30-Day Meal PlanPayment ConfirmationPLEASE READ BEFORE PURCHASE The Recipes provided herein contain ingredients that may cause allergic reaction in some individuals. These recipes are suggestions only. Do not make a recipe that contains ingredients that you are allergic to. If you are unsure about potential allergic reactions please consult your family physician. If you would like advice on how to replace certain ingredients feel free to email firstname.lastname@example.org Disclaimer: By purchasing this program, you accept and are bound by these terms and conditions without limitation, qualification or change. You represent that you have read and agreed to these terms and conditions at all times while using this program. You must be at least 18 years of age to access the material contained on dinezmerrao.com without adult supervision. To access and use dinezmerrao.com, you warrant that you are at least 18 years old or have obtained parental permission. Any application of the recommendations set forth in this website and program from Dinez Merrao Training Inc., DinezMerrao.com, or in any personal consultation by phone, email, in-person, or otherwise, is at the reader's discretion and sole risk. The information offered is intended for people in good health. Anyone with medical problems of any nature should see and consult a doctor before starting any diet or exercise program. Even if you have no known health problems, it is advisable to consult your doctor(s) before making major changes in your lifestyle. The material contained on DinezMerrao.com and in the DM Training Nutrition Plan, is provided for educational and informational purposes only and is not intended as medical advice. The information contained on this website and program should not be used to diagnose or treat any illness. All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. This information on this website has not been evaluated by the FDA and is not intended to treat, diagnose, cure or prevent any disease, metabolic disorder or health problems. We cannot and do not give you medical advice. You should seek prompt medical care for any specific health issues and consult your physician before purchasing any product(s). We do not recommend the self-management of health Signature*I agree to the terms and conditions mentioned above and I am 18 years or older.