Nutrition Assessment
Goals and Readiness, Medical, Diet, Lifestyle and General Health Questionnaire
Email address *
Name *
Please enter your full legal name.
Address *
Please enter your complete street address, city, state and zip code.
Phone Number *
Please provide your home phone or cell phone number where you can be reached.
Date of Birth *
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DD
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YYYY
Preferred method of contact *
Occupation *
How many hours in a day do you spend in a seated position?
Marital Status *
Are you pregnant? *
Due Date
Children *
Ages
Primary Care Provider *
Other Doctors or Practitioners you see *
Have you ever seen a Nutritionist before? *
I am visiting the nutritionist today because...
My food and nutrition-related goals are...
My overall health goals are...
The biggest challenge to reaching my health goals is/are...
In the past I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals...
Medical History: Please indicate if you have been diagnosed (in present time) with any of the following diseases or symptoms *
Required
Please list any medications, frequency, and dosage *
Please specify any surgeries you have had during your lifetime
How many times in one day do you pass a bowel movement? *
Is the consistency hard to pass, soft, or very loose?
Do you bowel movements float or sink?
Do you follow any special diet or have diet restrictions/limitations for any reason?
List any and all food allergies *
List any and all food sensitivities or intolerances (any food that causes stomach/head discomfort)
Who prepares majority of your meals?
How often do you grocery shop?
How often do you eat outside of your home per day?
How often do you eat out each week?
Which meals do you eat regularly? (Choose all that apply)
What time of the day do you eat your first meal?
What time of the day do you eat your last meal?
The nutrition/eating habits that are most challenging for me are...
The nutrition/eating habits I am most please with are...
Please list any food cravings you feel at any time of day or after meals
Please list any foods you would prefer to not eat
Please check each physical activity you participate in *
Required
Average time spent working out? *
Does anything limit you from being physically active? *
Do you have any reason(s) why you should not participate in physical activity? If yes, please explain.
What helps you relax/unwind?
Average hours of sleep per night
Do you smoke? *
Alcohol use? *
Drug use? *
What is your height? *
What is your current weight? *
Have you had recent changes in your weight you are concerned about? If yes, please explain.
Date of most recent blood test?
MM
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DD
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YYYY
How would you rate your health? (check one) *
One a scale of 1 (not ready) to 10 (very ready), how ready are you to make a lifestyle change? *
If you are not ready to make a lifestyle change, what are the barriers preventing you from becoming ready?
On a scale of 1 (not confident at all) to 10 (very confident), how confident are you to make lifestyle changes? *
If you chose 1-5, what would you need in order to become more confident?
A copy of your responses will be emailed to the address you provided.
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