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You are here: Home / Body Composition Questionnaire (Nutrition Clients Only)

Body Composition Questionnaire (Nutrition Clients Only)

Name*
FirstLast
Email*
Phone*
When I gain weight, I gain it everywhere
- True
- False
Comments
I started gaining weight at age
- 15-20
- 20-25
- 25-30
- 30-35
- 35-40
- 40-45
- 45-50
- 50+
- I've always been overweight
Comments
I used to be able to eat whatever I wanted and not gain any weight
- True
- False
Comments
I gain weight even though I don't eat much
- True
- False
Comments
If I'm late for a meal, I eat a large amount of food
- True
- False
Comments
My energy level is
- High
- Medium
- Low
Comments
Obesity runs in my family (50+ lbs. overweight)
- True
- False
Comments
I get hungry after I eat
- True
- False
Comments
I would describe myself as:
- Highly active
- Moderately active
- Slightly active
- Sedentary
Comments
To get my "ideal body", I would have to lose:
- 5-10 lbs
- 11-20 lbs
- 21+ lbs (please specify below)
Comments
I get irritated or shake if I don't eat every three hours
- True
- False
Comments
I find I am too muscular in certain areas
- True
- False
Comments
I believe my weight is hazardous to my health and well-being
- True
- False
Comments
I panic when I haven't eaten for a while
- True
- False
Comments
Parts of my body are too thin
- True
- False
Comments
When I'm more active I lose weight at an accelerated rate.
- True
- False
Comments
My entire body holds weight
- True
- False
Comments
My weight hinders my ability to exercise
- True
- False
Comments
My muscle seems solid no matter how much weight I gain
- True
- False
Comments
Although I am overweight, there are parts of me that aren't
- True
- False
Comments
I eat:
- Once a day
- Twice a day
- Three times a day
- Four times a day
- More than four times a day (please specify below)
Comments
I am physically:
- Weak
- Normal
- Strong
Comments
I have been a yo-yo dieter in the past
- True
- False
Comments
I gain weight in specific areas while other areas stay the same
- True
- False
Comments
I feel hungry post-exercise
- True
- False
Comments
Food calms me down
- True
- False
Comments
Food makes me happy
- True
- False
Comments
I feel regretful after eating poorly
- True
- False
Comments
I've had bouts of binge eating in the past
- True
- False
Comments
I used to be athletic, but now i am overweight
- True
- False
- Not overweight
Comments

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