Nutrition Planning Assessment
I am so excited to create you a delicious nutrition plan, designed specifically for your needs and to help you reach your health goals. Please complete this form to help me better understand your ambitions, typical diet, lifestyle, and preferences. Remember — there is no such thing as “too much information” here. The honest information you provide will help me create a comprehensive nutrition plan for you.🔒 All information shared will be kept strictly confidential.
Tell Me About You
Name
First Name
Last Name
Do you want to see changes in your body weight or composition? If so, describe the types of changes you would like to see.
What are your health, lifestyle, and dietary goals?
What do you hope to achieve through working with me?
Tell Me About Your Current Lifestyle
Do you exercise regularly?
Yes
No
If yes, how often and what type of exercise?
How much time are you willing to dedicate to exercise per week?
Do you feel your current diet is healthy?
Yes
No
If no, what do you think your current diet is lacking?
Do you have any digestive issues?
Yes
No
If yes, what kind and how often?
Do you have a bowel movement every day?
Yes
No
If no, how often?
Tell Me About Your Current Diet
How many times do you eat per day?
Describe your typical breakfast.
What time of the day do you eat breakfast?
Describe your typical lunch.
What time of the day do you eat lunch?
Describe your typical dinner.
What time of the day do you eat dinner?
Nutrition Planning
What is your motivation for seeking out a nutrition plan?
Are there any foods you will not eat due to sensitivities, allergies, or religious reasons?
How much time would you ideally want to spend in the kitchen per day?
How many people are you cooking for?
Are there times when it is difficult for you to buy the foods that you would like to buy?
What are the challenges to buying those foods?
Who does the grocery shopping and cooking in your household?
Do you have any challenges with preparing food?
Which food prep style best describes you?
I like to prep food in advance and eat the same meals for a few days
I want to spend more time cooking and have different meals each day
List some of your favorite proteins (chicken, fish, beef, turkey, tofu, eggs, etc.)
List some of your favorite carbs (vegetables, fruits, rice, pasta, potatoes, bread, tortillas, etc.)
List some of your favorite fat sources (avocado, olive oil, butter, nuts, seeds, cheese, etc.)
What are foods you don't like to eat/ don't want included in your meal plan?
What excites you about having or following a custom nutrition plan?
Is there anything that scares you or intimidates you about following a nutrition plan?
Is there anything else about yourself that you would like to share with me to help in building your nutrition plan?
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