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Initial Health/Nutrition Questionnaire
Please fill out as much of this form as possible prior to our visit
Date
Your answer
Name
Your answer
Gender
Your answer
Address
Your answer
DOB/Age
Your answer
Email Address/ Phone Number
Your answer
What is the primary purpose of you meeting with me?
Your answer
Why is this important to you?
Your answer
What are some short term goals?
Your answer
What are some long term goals?
Your answer
What do you hope to accomplish through our visits?
Your answer
How would define success as it relates to our meetings?
Your answer
Heath History
List any present/past medical diagnoses and or procedures
Your answer
Please list any mental health concern that I should be aware of? ( PTSD, Anxiety/Depression, etc)
Your answer
Please list any significant family medical history ( Diabetes, cardiovascular disease, thyroid, etc)
Your answer
Please list all medications that you are taking, prescription / over the counter
Your answer
Please list any supplements you are taking ( herbs, vitamins/mineral)
Your answer
Please list any food allergies/ intolerances and how were they diagnosed?
Your answer
Are menstrual cycles regular?
Your answer
Weight History
Height
Your answer
Current weight
Your answer
Have you lost or gained weight recently, explain.
Your answer
Do you have a goal weight and if so what is it?
Your answer
How would you feel if you did not get to your goal weight?
Your answer
Weight where you feel most comfortable and when were you last at that weight?
Your answer
Do you weigh yourself currently and if so how often?
Your answer
Please list your highest adult weight and lowest adult weight
Your answer
In general, how do you feel about your body
Physical Activity
Are you currently exercising on a regular basis, if Yes, describe
Your answer
Have you exercised consistently in the past? Describe.
Your answer
Tell me how you feel about exercise
Your answer
Any injuries?
Your answer
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