Middleway Method Therapeutic Nutrition Assessment Form
Use this form to begin your Therapeutic Nutrition Assessment. After I receive your completed form, I will contact you within 72 hours to schedule your free 30-minute consultation.

During your consultation, I will review your nutrition history and learn about your specific needs and preferences.

Then, we'll work together to develop a personalized nutrition plan.
Email address *
Name *
Phone Number *
Your Age
Height *
Weight *
What are your goals?
What is your current dietary preference? *
Do you consider yourself...
What is your current blood pressure?
Clear selection
What medical conditions do you have now or have you had in the past?
What medications, if any, are you taking at this time?
How often do you exercise? *
Days a week
Briefly describe the kinds of exercise that you do:
How often do you eat more than one cookie equivalent of refined white sugar per day? *
Days a week
How often do you drink more than one cup coffee or caffeinated soda per day? *
Days a week
How often do you drink more than one alcoholic beverage per day? *
Days a week
How often do you smoke more than one cigarette per day?
Days a week
Clear selection
How many hours on average per night do you sleep? *
How many glasses of pure water do you drink per day, on average? *
What is your usual stress level? *
Total equanimity
Debilitating anxiety
How often do you do delightful, stress-relieving activities? *
Days a week
Briefly describe the delightful, stress-relieving activities that you do.
How did you discover Middleway Method *
Completing this questionnaire so far, you can see that getting adequate exercise, sleep, hydration and enjoyment, and limiting sugar, caffeine and alcohol intake are essential for healthy tissue regeneration (healing). Knowing this, how willing are you to make substantive lifestyle changes where necessary? *
Totally enthusiastic
Please use the space below to ask questions and share important information that was not covered in this questionnaire:
A copy of your responses will be emailed to the address you provided.
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