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 *
Your answer
Phone Number *
Your answer
Your Age
Your answer
Height *
Your answer
Weight *
Your answer
What are your goals?
What is your current dietary preference? *
Required
Do you consider yourself...
What is your current blood pressure?
What medical conditions do you have now or have you had in the past?
Your answer
What medications, if any, are you taking at this time?
Your answer
How often do you exercise? *
Never
Days a week
Briefly describe the kinds of exercise that you do:
Your answer
How often do you eat more than one cookie equivalent of refined white sugar per day? *
Never
Days a week
How often do you drink more than one cup coffee or caffeinated soda per day? *
Never
Days a week
How often do you drink more than one alcoholic beverage per day? *
Never
Days a week
How often do you smoke more than one cigarette per day?
Never
Days a week
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? *
Never
Days a week
Briefly describe the delightful, stress-relieving activities that you do.
Your answer
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? *
Unwilling
Totally enthusiastic
Please use the space below to ask questions and share important information that was not covered in this questionnaire:
Your answer
A copy of your responses will be emailed to the address you provided.
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