Diet assessment
Helping you move forward with 2-3 actionable steps you can implement immediately
Phone Number
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Name
First Name
Last Name
Email
example@example.com
What is your age/weight/height?
How many meals a day do you eat?
How many snacks do you eat in a day
How much protein do you eat in a day? If you don't know grams or ounces, do you have a serving of protein at each meal? What kinds of proteins do you eat?
How many carbs do you eat in a day? If you don't know grams or ounces, list the carbohydrates that you eat in a regular day/week.
Do you know how many calories you eat in a day or how many you should be eating? If yes, please share that number.
How many meals a week do you eat out? (This includes all food that isn't prepared inside your home--ie: Grubhub, drive-thru, meals prepared by someone for you outside of your home)
How many steps do you get in a day?
If you have dieted in the past, what is the most recent diet you have tried? When? For how long? Did you lose weight? How much? Were you able to keep it off?
Are you experiencing any symptoms related to perimenopause or menopause? For how long? Are you taking anything? (Hormones, supplements)
What are you current goals? Weight loss? How much weight do you want to lose? Longevity and overall health? What would that look like for you?
Are you working out or performing intentional movement (walking, yoga, etc.)? How often? What is the duration of the workouts?
What time is your last meal/snack and what time do you go to bed?
How many alcoholic drinks per week?
What is your daily hunger level
Never hungry
Hungry at mealtime
Hungry in the afternoon
Hungry/wanting an after dinner snack
Always full/satisfied
Other
Do you have cravings for snacks?
Yes, salty
Yes, sweet
Both
None
Other
How is your sleep
Amazing-sleep like a baby every night
I fall asleep easily, but can't stay asleep
I wake up several times a night and fall right back to sleep
I wake up several times a night and toss and turn
I sleep mostly well, but wake up around 3:00am and can't fall back to sleep
Other
Is there any additional information you would like to share? Medications? Surgeries, limitations?
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