Nutrition Consultation Form

Name

First NameLast Name

Age

Date of Birth

Date

Phone Number

Format: (000) 000-0000.

Email

example@example.com

How do you prefer me to contact you? eg. email, phone, text.

Emergency contact name and number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Weight (kg)

Current Height (cm)

Desired Body Weight (kg)

Your main health goals are focused around? please list below:

List all of your concerns about your health, eating habits, fitness and/or body

Out of all the above concerns, which ones feel most important/urgent and why?

Do you have any preference in food diet?

If yes, what are they?

Have you followed any diet trend?

Was the diet trend you followed effective?

Please share the diet trend you followed and the effectiveness here.

Leave blank if the answer is no.

Which of those things worked well for you? (Even if you might not be doing them now)

Which of those things didn't work well for you?

How specifically, would you like your habits, your health, your eating and/or your body to be different?

Have you already made changes to your habits, your health, your eating, and/or your body? If so, what?

Until now, what has blocked you or held you back from changing these things?

Right now, how would you rank your overall eating/nutrition habits?

Do you have any eating disorder?

If yes, please share it here so that we are aware about it.

Have you been diagnosed (currently or in the past) with any significant medical conditions and/injuries?

If you have ticked 'Yes' to the above question, please explain in more detail:

Right now, do you have any specific health concerns, such as illness, pain, and/or injuries?

If you have ticked 'Yes' to the above question, please explain in more detail:

Do you have any allergies? If yes, please list them below:

Are you currently taking any medications? If yes, please list them below:

This includes vitamins, supplements, and other medications you're taking

Please check below if you have any of the current health conditions:

Rows	Present	Condition Name	Remarks
Gastrointestinal
Respiratory
Cardiovascular
Neurological
Dermatological
Musculoskeletal
Urinary
Reproductive
Metabolic
Endocrine
Cancer
Other

If 'ticked' other, please specify.

Are you smoking?

Are you drinking alcohol?

If yes, how many times per week.

Are you a vegetarian?

What caffeinated beverages are you drinking? What time of the day do you have these?

On a scale 1-5, how would you rank your health right now?

1 is Worst, 5 is Best

Are you regularly active in sports/gym and/or exercise? If so, approximately how many hours per week?

What type of sport and/or exercise do you typically do? How many times per week?

Approximately how many hours a week do you do other types of physical activities? (eg, housework, walking, home repairs, moving around work, gardening)

What's around you?

Do you have children? If so, how many?

Who does most of the grocery shopping in your household?

Who does most of the cooking in your household?

Who decides on most of the menu/meal types in your household?

Right now, how much do the people and things around you support health, fitness, and/or behavioural change?

What do you expect from me as your nutritionist?

What are you prepared to do to work towards your goals?

How is your stress and recovery? Think about all the activities you're involved in (work, school, caregiving, housework, travel). Then assess as best as you can: Given all the demands of your life, what is your typical stress level on an average day?

1 is No stress, 5 is Extreme

On average, how many hours per night do you sleep?

How do you normally cope with stress?

How READY are you to change your behaviours and habits?

1 is Not at all, 5 is Completely

How WILLING are you to change your behaviours and habits?

1 is Not at all, 5 is Completely

How ABLE are you to change your behaviours and habits?

1 is Not at all, 5 is Completely

Client signature