Client Assessment Questionnaire
Avocado Ali Initial YOU-based NUTRITION Application - Once your questionnaire has been reviewed we will email you to set up your discovery call. Be completely honest and authentic and we look forward to talking with you soon with real solutions around the corner!
Email address *
Name: *
Your answer
Phone: *
Your answer
Gender: *
Age: *
Your answer
Height: *
Your answer
Weight: *
Your answer
Medical Concerns: *
Your answer
Indicate if you have blood relatives with any of the following:
Do you have complaints about any of the following?
Do you use tobacco in any way? *
If yes, how much/often?
Your answer
Did you recently stop smoking? *
How much physical activity do you participate in? *
What types of physical activity do you enjoy? *
Your answer
List any food allergies or intolerances:
Your answer
Which of the below issues (pick as many as apply) do you struggle with? *
Required
List any prescribed, over-the-counter, or vitamin/mineral supplements you take:
Your answer
Do you follow any special dietary plan (ie: low cholesterol, kosher, vegetarian)?
Your answer
Have you ever followed a special diet? *
If yes, please explain:
Your answer
Are there certain foods that you do not eat?
Your answer
Do you eat at regular times each day? *
How often do you eat each day? *
Your answer
What foods do you particularly like? *
Your answer
Do you drink alcohol? *
If yes, how often?
Your answer
What changes would you like to make? *
Required
Please add any additional information you feel may be relevant to understanding your nutritional health:
Your answer
In order to tailor your counseling experience to your needs, it would be useful to know your expectations. Please choose one of the following to indicate the amount of structure you believe meets your needs: *
What is the highest level of education you received? *
Your answer
Are you employed? *
Occupation:
Your answer
How many people live in your household? *
Your answer
Ages of those living in your household?
Your answer
Present marital status: *
Do you have a refrigerator? *
Do you have a stove? *
Who prepares most of the meals in your home? *
Your answer
Who shops for groceries? *
Your answer
How often do you eat out? *
Your answer
Where do you prefer to dine out? *
Your answer
What recent food changes have you made in your life (if any)?
Your answer
What are your health goals? *
Your answer
Who could support and encourage with you to make the changes necessary to reach your goals? *
Your answer
What information would you like from your nutrition counselor? *
Required
How would you like to be contacted? *
What are the best times for a phone consultation? *
Required
What are the best days for a phone consultation? *
Required
A copy of your responses will be emailed to the address you provided.
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