Holistic Nutrition Counseling
With Nahomy's Naturals
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
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What are your health goals when working with me? What is it that you want to accomplish?
What medical concerns, if any, do you have?
If keeping track of your weight is one of your health goals, please add your current weight here.
Drink alcohol?
Smoke cigarettes?
List any food allergies or intolerances.
List any prescribed OTC medications, herbal supplements, or vitamins/minerals you take.
DIET HISTORY
Do you currently follow a dietary plan? (vegetarian, pescatarian, keto, vegan, etc.)
Is there anything that runs in the family?
List any foods you do not eat.
List your favorite foods! For breakfast, lunch, dinner, and snack. Add your favorite drinks too.
What changes would you like to make?
Improve my eating habits
Learn to manage my weight
Become more aware of my body
Improve my activity level
Other
Please add any additional info that is relevant to comprehending your nutritional health.
In order to tailor your counseling experience to your needs, it will be useful to know your expectations. Please check one of the following to indicate the amount of structure you believe meets your needs:
I want a lot of structure but freedom to select foods. I want a detailed food plan. (For example, 3 fruit, 2 grain, 1 protein)
I don't want a structured diet. I just want to eat better. I want to set food goals.
Aside from having a set food plan, what other information would you like from your nutritionist?
Healthy food preparation
Food labels
Mind & body (meditation/crystals)
Eating out
Meal planning
Journaling
Other
Do you have any of the following? Check each one.
constipation
no appetite
menstrual difficulties
high stress
anxiety
sudden changes in weight
bleeding gums
difficulty sleeping
bloating
gassy/burps
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