Therapeutic Nutrition Plan – Fitsyfy

Get Your Therapeutic Nutrition Plan

Therapeutic Nutrition — Designed with Medical Precision
🩺 Considers your health conditions, medications, and recovery goals
🧠 Combines clinical insight with FITSYFY’s evidence-based approach
💪 Supports healing, metabolism, and long-term wellness
🔘 Request Your FITSYFY Therapeutic Nutrition Program

Therapeutic Nutrition Program Questionnaire New

Personal Information
Body Composition
Activity & Primary Goal
Dietary Preferences
Medical Fitness Declaration

STEP 1 — Personal Information

Full Name

Used for accurate records and client support.

We’ll deliver your plan and updates to this email.

Phone/Mobile

We’ll deliver your plan and updates to this email.

Age (Years)

Age influences energy needs, recovery, and macro planning.

Gender

Used for formula selection and category references.

STEP 2 — Body Composition

Weight (kg)

Waist

Men: at navel
Women: at narrowest point

Height (cm)

Neck

Below Adam’s apple

Hips

Measurement Guidance: Use a flexible tape; measure snug (not tight), parallel to the floor, after a normal exhale. Take 3 readings per site and use the average. Men: waist at navel. Women: waist at narrowest; hips at widest over buttocks.

Conversion Container

Height in Meters

Height in Inches

Neck in Inches

Waist in Inches

Hips in Inches

STEP 3 — Activity & Primary Goal

Activity Level

Activity_Level_Total

Primary Goal (select one)

Weight/Fat Loss — reduce body fat with a calorie deficit.

Body Recomposition — build muscle while losing fat.

Hypertrophy (Muscle Gain) — increase muscle size with a slight calorie surplus.

Strength — increase maximal force with performance‑focused fueling.

STEP 4 — Dietary Preferences

A. Diet Preference (Choose ONE)

Vegetarian

Vegan

Omnivore (No restrictions)

Eggetarian (Vegetarian with eggs)

REASON: Ensures your diet plan aligns with your ethical, cultural, or health‑based choices.

B. Preferred Diet Type (Choose one or more)

Balanced Diet (General healthy eating)

Ketogenic (Low-carb, high-fat)

Paleo (Whole, unprocessed foods)

Mediterranean (Plant-rich, heart-healthy fats)

Bodybuilding Diet (High-performance muscle gain)

Intermittent Fasting (Time-restricted eating) — e.g., Warrior Diet, OMAD (One Meal A Day)

REASON: Helps structure your plan according to your personal and lifestyle‑based preferences.

STEP 5 — Medical Fitness Declaration

(To help our experts design a safe, therapeutic, and effective nutrition plan tailored to your health status.)

A. Chronic Health Conditions: Do you have any ongoing or diagnosed medical conditions?Chronic Health Conditions

Yes

Chronic Health Conditions (If Yes)

Type 2 Diabetes / Prediabetes

Type 1 Diabetes

Thyroid Disorder (Hypo / Hyper)

Hypertension (High Blood Pressure)

Dyslipidemia (High Cholesterol / Triglycerides)

PCOS / PCOD

GERD / Acid Reflux

IBS / IBD (Digestive Issues)

Fatty Liver

Kidney Disorder

Heart Disease

Gout / High Uric Acid

Osteoporosis / Low Bone Density

Anemia / Vitamin Deficiency

Chronic Health Conditions - Others (Please Specify)

Reason: Chronic conditions can impact metabolism, nutrient absorption, and require specific dietary modifications.

B. Medications: Are you currently taking any prescribed medications or supplements?

Yes

Medications (If Yes)

Antidiabetic (e.g., Metformin, Insulin)

Thyroid Medication (e.g., Eltroxin)

BP Medication (Antihypertensives)

Statins (Cholesterol-lowering)

Steroids / Corticosteroids

Blood Thinners / Anticoagulants

Antidepressants / Mood Stabilizers

Painkillers / NSAIDs

Proton Pump Inhibitors (PPI / Antacids)

Vitamin / Mineral Supplements

Medications - Others (Please Specify)

Reason: Some medicines alter metabolism, appetite, or nutrient needs. We adjust your diet accordingly.

C. Allergies / Food Intolerances: Do you have any known food allergies or intolerances?

Yes

Allergies (If Yes)

Gluten / Wheat

Lactose / Dairy

Eggs

Soy

Peanuts / Tree Nuts

Fish / Shellfish

Sesame

Nightshade Vegetables (e.g., Tomato, Potato)

High‑FODMAP Foods

Allergies / Food Intolerances - Others (Please Specify)

Reason: This ensures your plan excludes trigger foods and includes safe, digestible alternatives.

I confirm that I am medically & physically fit and have no known conditions requiring dietary restrictions.
I understand this plan is based solely on the information I provide.
I acknowledge this is a fitness/wellness plan, not medical treatment.

Signature (type your name)

Date

Body Mass Index

Male Body Fat %

Lean Body Mass (LBM) - Male

Basal Metabolic Rate (BMR) - Male

Maintenance Requirement (TDEE/MR)

Female Body Fat %

Lean Body Mass (LBM) - Female

Basal Metabolic Rate (BMR) - Female

Maintenance Requirement (TDEE/MR) - Female

Male Result

Protein/g

Fat/g

Carb_kcal

Carb_g

Female Result