Nutrition Consultation Form
Fill out what you’re most comfortable sharing
Date of Birth
Current Weight (kg)
Current Height (cm)
Desired Body Weight (kg)
Reasons why you want to go on diet
What are your nutrition goals?
Do you have any preference in food diet?
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.
Do you have any eating disorder?
If yes, please share it here so that we are aware about it.
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:
Are you smoking?
Are you drinking alcohol?
Are you a vegetarian?
What caffeinated beverages are you drinking?
If you play sports, please list them below and indicate how often?
Do you go to the gym? How often do you exercise?
Meal Plan / Nutritional Log: In your estimate, what are the foods and liquids are you usually taking in a daily basis?
Should be Empty: