Nutrition Consultation Form
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
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
City
State / Province
Postal / Zip Code
Current Weight (kg)
Current Height (cm)
Desired Body Weight (kg)
Reasons why you want to go on diet
What are your nutrition goals?
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?
Yes
No
If yes, what are they?
Have you followed any diet trend?
Yes
No
Was the diet trend you followed effective?
Yes
No
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?
Clean
Healthy
Average
Could be better
Not good
Do you have any eating disorder?
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
Are you drinking alcohol?
Yes
No
If yes, how many times per week.
Are you a vegetarian?
Yes
No
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?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Are you regularly active in sports/gym and/or exercise? If so, approximately how many hours per week?
Fewer than 5 hrs
5-9 hrs
10-14 hrs
15-19 hrs
20 or more hrs
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)
fewer than 5 hrs
5-9 hrs
10-14 hrs
15-19 hrs
20 or more
What's around you?
Spouse/partner
Room mates
Child(ren)
Pet(s)
Other family
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?
Completely
Sometimes
Rarely
Not at all
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?
No stress
1
2
3
4
Extreme
5
1 is No stress, 5 is Extreme
On average, how many hours per night do you sleep?
4 or fewer hrs
5 hrs
6 hrs
7 hrs
8 hrs
9 hrs
10 hrs
How do you normally cope with stress?
How READY are you to change your behaviours and habits?
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
How WILLING are you to change your behaviours and habits?
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
How ABLE are you to change your behaviours and habits?
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
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