Nutrition: Assessment | Dinez Merrao

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DM Training Nutrition Assessment

Step 1 of 9

General Information
1. Name*
First Last
2. Email*
3. Phone*
4. Sex:*
5. Age:*
6. Height:*
7. Current Body Weight:*
8. Lean Body Mass (if known):
9. Body Fat % (if known):

MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE
1. Please provide the names of medications, supplements and or/ antibiotics you are currently taking. Include dosage and frequency
Name Dosage Frequency (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?*
If yes, please indicate here:
3. Do you have any allergies or dietary restrictions?*
If yes, please indicate here:

WORKPLACE ASSESSMENT
1. Please provide your normal weekly work schedule. If not applicable, input "N/A"*
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
2. Please provide the break/ lunch time (s) you are allotted at work. If none, input "N/A"*
Break time Duration
3. 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 up Bedtime Naps (if any)

1. Please indicate how often you consume water during a normal week*
Tap Filtered Bottled
2. Please indicate how often you consume coffee during a normal week*
Regular Decaf Latte
3. Please indicate how often you consume tea during a normal week*
Unsweetened Sweetened Herbal
4. Please indicate how often you consume juice during a normal week*
Natural Artificially Flavored Fruit Juice
5. Please indicate how often you consume soda during a normal week*
Regular Diet
6. Please indicate how often you consume milk during a normal week*
Whole 2% 1% Skim
7. Please indicate how often you consume milk alternatives during a normal week*
Almond Milk Soy Milk
8. Please indicate how often you consume alcohol during a normal week.*
Wine Beer Liquor
9. List any other beverages that you consume during a normal week that are not mentioned above

Select Meal Plan*
Payment Confirmation
PLEASE 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 dinezmerraotraining@gmail.com 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.

Type of Training	Day of week	Session begins (am/pm)	Session ends (am/pm)

DM Training Nutrition Assessment

Step 1 of 9

General Information

Goals and Readiness

On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/ willingness to do the following:

MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE

ACTIVE LIFESTYLE ASSESSMENT

WORKPLACE ASSESSMENT

What is your daily sleep schedule?

DIETARY & EATING HABITS ASSESSMENT

Payment Confirmation

Name	Dosage	Frequency (daily)

Time consumed	Item description	Quantity

Time consumed	Item description	Quantity

Time consumed	Item description	Quantity