Nutrition Assessment
Goals and Readiness, Medical, Diet, Lifestyle and General Health Questionnaire
* Required
Email address
*
Your email
Name
*
Please enter your full legal name.
Your answer
Address
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Please enter your complete street address, city, state and zip code.
Your answer
Phone Number
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Please provide your home phone or cell phone number where you can be reached.
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Preferred method of contact
*
E-mail
Phone Number
Text Message
Occupation
*
Your answer
How many hours in a day do you spend in a seated position?
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Your answer
Marital Status
*
Married
Divorced
Single
Are you pregnant?
Yes
No
Clear selection
Due Date
Your answer
Children
*
Yes
No
Ages
Your answer
Primary Care Provider
*
Your answer
Other Doctors or Practitioners you see
*
Your answer
Have you ever seen a Nutritionist before?
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Yes
No
I am visiting the nutritionist today because...
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Your answer
My food and nutrition-related goals are...
Your answer
My overall health goals are...
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Your answer
The biggest challenge I have with reaching my health goal(s) is/are...
Your answer
Please list the past techniques, diets, behaviors, etc. you have tried to reach your nutrition goals.
Your answer
Medical History: Please indicate if you have been diagnosed (in present time) with any of the following diseases or symptoms
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Allergies
Anemia
Anxiety or Panic Attacks
Arthritis (osteoarthritis or rheumatoid)
Asthma
Autoimmune Condition
Bronchitis
Cancer
Chronic Fatigue Syndrome
Chron's Disease or Ulcerative Colitis
Depression
Diabetes (Type I, II, Prediabetes, Gestational)
Dry, Itchy skin, rashes, dermatitis
Eczema
Emphysema
Epilepsy, convulsions, or seizures
Eye Disease
Fibromyalgia
Food Allergies or Sensitivities
Fungal Infection (Athlete's foot, ringworm)
Gallbladder Disease/Gallstones
Gout
Heart Attack/Angina
Heartburn
Heart Disease
Hepatitis
High Blood Fats (Cholesterol, Triglycerides)
Hypoglycemia (low blood sugar)
Intestinal Disease
Inflammatory Bowel Syndrome (IBS)
Kidney Disease
Lung Disease
Liver Disease
Mononucleosis
Osteoporosis
PMS
Polycystic Ovarian Syndrome
Pneumonia
Prostate problems
Psychiatric conditions
Sinusitis
Sleep Apnea
Stroke
Thyroid Disease (hypo- or hyper-)
Urinary Tract Infection (UTI)
Other:
Required
Please list any medications you are currently taking
*
Your answer
Please list the dosage and frequency of each medication you are currently taking
*
Your answer
Please list all supplements you consume daily, weekly, or monthly
*
Your answer
Please specify any surgeries you have had during your lifetime
Your answer
How many times in one day do you pass a bowel movement?
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Your answer
Is the consistency hard to pass, soft, or very loose?
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Hard to pass
Soft
Very loose
Do your bowel movements float or sink?
*
Your answer
What is the date of your last menstrual cycle?
MM
/
DD
/
YYYY
Do you have a menstrual cycle each month?
Yes
No
Clear selection
Is your menstrual cycle irregular?
Yes
No
Clear selection
Do you take birth control?
Yes
No
Clear selection
Please list any symptoms or concerns regarding your menstrual cycle.
Your answer
Do you follow any diet restrictions/limitations for any reason? (example: gluten due to celiac or gluten due to stomach discomfort, brain fog, etc.)
Your answer
List any and all food allergies
*
Your answer
List any and all food sensitivities or intolerances (any food that causes stomach/head discomfort)
*
Your answer
Who prepares majority of your meals?
Your answer
How often do you grocery shop?
*
1-3x/week
3-6x/week
2x/month
Other
How often do you eat outside of your home per day?
*
Breakfast
Lunch
Dinner
All Meals
None
How often do you eat out each week?
*
1-2x/week
2-3x/week
4 or more times per week
Which meals do you eat regularly? (Choose all that apply)
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1
2
3
Required
Do you snack throughout the day?
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Yes
No
What time of the day do you eat your first meal?
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Your answer
What time of the day do you eat your last meal?
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Your answer
What nutrition/eating habits are most challenging for you?
Your answer
What habits have you created with nutrition/food that you are proud of?
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Your answer
Please list any food cravings you feel at any time of day or after meals.
Your answer
Please list any foods you would prefer to not eat.
Your answer
Please check each physical activity you participate in
*
Stretching/Yoga
Cardio/Aerobics
Sports or Leisure
Strength Training
Other:
Required
Average time spent working out?
*
Your answer
How many days a week are you physically active?
*
Your answer
Does anything limit you from being physically active?
*
Your answer
Do you have any reason(s) why you should not participate in physical activity? If yes, please explain.
Your answer
What helps you relax/unwind?
Your answer
Average hours of sleep per night
Your answer
During the week, what time do you wake up and go to sleep?
Your answer
On the weekend, what time do you wake up and go to sleep?
Your answer
Do you smoke?
*
Never
In the past
Yes
Alcohol use?
*
Never
In the past
Yes
Drug use (cannabis)?
*
Never
In the past
Yes
What is your height?
*
Your answer
What is your current weight?
*
Your answer
Have you had recent changes in your weight you are concerned about? If yes, please explain.
Your answer
Date of most recent blood test?
MM
/
DD
/
YYYY
Can you obtain a copy of your results?
Yes
No
Clear selection
How would you rate your health? (check one)
*
Poor (I do not give my health very much attention)
Fair (I am aware of what could be better options for my health)
Good (I make it appoint to choose options that will better my health)
Excellent (My health is top priority and I know that if I eat well, I will feel my best)
One a scale of 1 (not ready) to 10 (very ready), how ready are you to make a lifestyle change?
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1
2
3
4
5
6
7
8
9
10
If you are not ready to make a lifestyle change, what are the barriers preventing you from becoming ready?
Your answer
On a scale of 1 (not confident at all) to 10 (very confident), how confident are you to make lifestyle changes?
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1
2
3
4
5
6
7
8
9
10
If you chose 1-5, what would you need in order to become more confident?
Your answer
A copy of your responses will be emailed to the address you provided.
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