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By completing this questionnaire, you consent to Orena Health Inc. collecting and using your health information to provide personalized wellness recommendations, nutrition plans, exercise plan and follow-up services. This questionnaire is intended for health screening and wellness purposes and does not provide a medical diagnosis or replace advice from a qualified healthcare professional.
Your Name:
Your Email (Used to Return your Meal & Exercise plan ):
Your Occupation:
Your Address:
Questions for Exercise Plan
Select your Fitness Goals: NoneLose Body FatWeight LossWeight GainMaintain Current WeightImprove My Body's PhysiqueImprove HealthBuild muscleTo Gain StrengthStress ReliefRehabilitation (Recover from Illness)Managing DiseaseImprove Athletic PerformanceIncrease stamina and EndureIncrease Daily Energy Levels
State Other Fitness Goals:
How would you describe your daily activity level? NoneSedentary (little to no moving around, work a desk)Light Active (light exercise 1-3 days per week)Moderately Active (moderate 3-5 days of exercise)Very active (6-7days)Extremely active
How Often Do you Exercise? Multiple Times DailyOnce Daily5+ days/week3–4 days/Week1–2 days/WeekOnce a MonthNever
What type of exercise do you usually do? Free WeightsFixed ResistanceCardio (Running, Walking Treadmill, Bike, etc.)Group Classes (Spin, Zumba, etc.)Holistic (Yoga, Mobility, Pilate etc.)None
Your Target Weight:
Daily Activity Level (Outside of the gym): NoneSedentary (Desk job, very little movement)Lightly Active (Desk job but I walk around occasionally)Moderately Active (On my feet a lot, e.g., retail, nursing, teaching)Very Active (Physical labor job, e.g., construction, landscaping)
Do you have any current or past injuries? If yes, please describe location and severity:
Do you have any Immobilities? If yes, list them:
Are there exercises or activities you like and want to do:
Are there exercises or activities you dislike or want to avoid:
How much time can you spend per exercise session?
Medical Questions
Medical Conditions Affecting Diet (Check all that apply): NoneType 1 or Type 2 DiabetesHigh Blood Pressure/HypertensionHigh CholesterolIBS / Digestive Issues (Bloating, gas, etc.)Acid Reflux / GERDPCOS (Polycystic Ovary Syndrome)Thyroid ConditionKidney DiseaseGastrointestinal DiseaseCardiovascular Diseases
List any other Medical Conditions:
Are you on any medications?
Current Supplements: Creatine MonohydratePre-Workout / CaffeineFish Oil / Omega-3sMultivitaminVitamin AVitamin BVitamin CVitamin DIronMagnesiumZincBCAAs / EAAsProtein powersHerbal supplementsNone
Questions for Meal Plan
Check all that apply to your eating style, Current Dietary Style: No PreferenceVegetarian (No meat, but eat dairy/eggs)Vegan (No animal products)Pescatarian (Vegetarian + Seafood)Paleo (unprocessed foods – hunted, fished or gathered)Gluten-FreeKetoHalalKosher
State other Diets:
Food Allergies or Severe Intolerances (Check all that apply): NoneGluten / WheatDairy / LactoseEggsSoyNuts / PeanutsShellfishFish
Other Food Allergies and Foods you Avoid:
List foods you do not eat for religious or cultural reasons:
Preferred Number of Meals Per Day: One Meal Per DayOne Meal Per Day with Snack2 Large Meals Per Day (e.g., Skip breakfast)2 Large Meals Per Day with Snack3 Standard Meals (Breakfast, Lunch, Dinner)3 Standard Meals (Breakfast, Lunch, Dinner and Snack)4 Meals (Standard meals + 1 snack)5+ Smaller Meals with Snack
Cooking Skill Level: I Can't/don't CookBeginner (I burn water / Use microwave only)Intermediate (I can follow a recipe and cook basics like chicken and rice)Advanced (I enjoy cooking complex meals from scratch)
Daily Meal Prep Time Available: I don't have time to cookLess than 15 minutes15 – 30 minutes15 – 30 minutes30 – 60 minutesI have plenty of time to cook
How do you usually prepare your food? No PreferenceBakedFryAir-fryRoastBoilSteamGrill
Food Budget Preference: Budget-friendly (Cheaper cuts of meat, basic staples)Moderate (Willing to spend a bit more for convenience like pre-cut veggies)Flexible / Premium (Organic, grass-fed, wild-caught, etc. is preferred)
Food Likes and Dislikes
Proteins you enjoy: NoneChicken Breast / ThighsLean Beef (Sirloin, 93% lean ground)Fatty Beef (Ribeye, 80% lean ground)Pork (Chops, Tenderloin)Turkey (Ground, Deli meat)Salmon / Fatty FishWhite Fish (Tilapia, Cod, Tuna)Shrimp / SeafoodEggs / Egg WhitesGreek Yogurt / Cottage CheeseProtein Powder (Whey, Casein, Plant-based)
Carbohydrates you enjoy: NoneWhite RiceBrown Rice / QuinoaOatmealPotatoes (White)Sweet Potatoes / YamsPasta / SpaghettiBread / Wraps / BagelsFruit (Bananas, Berries, Apples, etc.)Beans / Lentils / Legumes
Fats you enjoy: NoneAvocados / GuacamoleOlive Oil / Avocado OilPeanut Butter / Almond ButterNuts (Almonds, Walnuts, Cashews)Seeds (Chia, Flax, Sunflower)CheeseButter
Vegetables you enjoy: NoneBroccoliSpinach / KaleAsparagusGreen BeansBell Peppers / OnionsZucchini / SquashCarrots / Peas / CornSalads (Mixed greens)
Popular Foods
How often do you consume fruits? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume vegetables? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume legumes? (e,g lentil pea, chickpeas, etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat nuts? (E.g. peanuts, almonds, walnuts, etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat ultra- processed meat? (E.g. hotdogs, bacon, etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you drink milk? NeverNeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat cereals? (e.g. oats, cream of wheat, barley)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat rice (e.g. brown rice, white rice, jasmine rice etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat starchy foods? (E.g., potatoes (English, sweet, pumpkin, yams, etc)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat bread? (E.g. white, whole wheat, etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat eggs? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat meat? (Chicken, pork, beef, etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat red meat? (Lamb, Pork etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you eat fish? (Flying fish, dolphin, shark etc.)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume fried foods (chips, chicken, fish, etc)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume snacks (eg.,Corncurls, Shirley’s, potato chips, etc)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume sugar-sweetened beverages (soft drinks)? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
How often do you consume energy drinks? NeverOnce a month2 times per month3 times per monthOnce a week2 times per weekMore than 3 times per weekOnce a day2 times per dayMore than 2 times per day
List your most Favourite Foods:
Lists Foods you really Dislike:
Hydration & Supplementation
Daily Water Intake: Less than 32 oz (1 Liter)32 oz – 64 oz (1 – 2 Liters)64 oz – 96 oz (2 – 3 Liters)Over 1 Gallon (3.5+ Liters)
Daily Beverages: Water onlyBlack Coffee / Plain TeaCoffee/Tea with sugar, cream, or flavored syrupsDiet Sodas / Zero-calorie energy drinksRegular Sodas / Sugary DrinksAlcohol (1-2 drinks nightly/often)None
Would you be willing to Review this Nutrition and Fitness Service: YESNO
I consent to submitting my medical data strictly to generate my meal plan: YES
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