Hite Nutrition Client Assessment
Please help me get to know you a little better by answering a few questions...
First and Last Name: *
Your answer
Date of Birth: *
Your answer
Address:
Your answer
Best phone number to reach you at: *
Your answer
Email Address: *
Your answer
Height:
Your answer
Current Weight:
Your answer
Occupation (and hours of work): *
Your answer
What is your current marital status?
Health History
*Please answer the following questions to the best of your abilities.
What medical concerns, if any, do you have currently?
Your answer
Indicate if you have had blood relatives with any of the following problems:
Do you ever find yourself complaining of any of the following? (choose all that apply)
Do you use tobacco in any way? If so, how often? *
Your answer
Do you enjoy physical activity? If no, please explain why... *
Your answer
How many times a week are you active between 30 - 60 minutes a day?
How many hours of sleep do you get on an average weeknight?
Your answer
Please list any food allergies or intolerances you are aware of: *
Your answer
Please list any prescribed or over-the-counter medications, herbal supplements, or vitamin/mineral supplements you take. *
Your answer
Diet History
***If you do not know how to answer the following questions that is totally ok! That is why I am here, please just answer to the best of your ability and we will talk through them at our first meeting.
Are you currently following any special dietary plan? Such as low cholesterol, kosher, vegetarian, or vegan... *
If yes, which dietary plan?
Do you have any problems purchasing foods that you want to buy? (economical, transportation, education) *
Who prepares most of the food in your household? *
Your answer
Do you use convenience foods daily? (ex: lunch meat, ready-to-go soups, granola bars, fruit cups, microwave dinners….) *
Are there certain foods that you do not eat currently? If so, please list them here:
Your answer
What are some of your favorite foods and/or meals to eat? *
Your answer
What are some of your least favorite foods? *
Your answer
Do you eat at regular times in the day? (Breakfast, Lunch, Dinner) *
How many times on an average day do you eat a regular meal? (be honest) *
Do you drink alcohol? *
If so, how often?
Do you drink soda? (regular or diet) *
If so, how often?
What changes are you hoping to make? (choose all that apply) *
Required
Please tell me of any past successes or negligences you have encountered with your nutritional health. *
Your answer
Do you have someone in your life who will support you and encourage you in nutrition and lifestyle changes? *
If so, who?
Your answer
Please tell me anything that has not been touched on throughout this questionnaire that I should know about your nutritional habits and/or health. *
Your answer
If you would like help structuring your meals, please identify the amount of structure you believe meets your needs: *
Please let me know what you would like more information about (check all that apply):
*Thank you for taking the time to complete this form. I really appreciate your honesty as we work together to help you become a more healthier you!
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