MNSV Consultant, Coach & Research - Health, Nutrition & Lifestyle Assessment Form

MNSV Consultant, Coach & Research Health Nutrition & Lifestyle Assessment Form

Please complete this form prior to your consultation. All information provided is confidential and used solely to support your personalised nutrition and wellness plan.
YOUR DETAILS
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about us?

Other
Were you referred by a medical specialist?
If yes, please provide the specialist type and name
HEALTH & BODY COMPOSITION
Current Weight (kg)
Height (cm)
Goal Weight (if applicable) (kg)
Body Fat Percentage (if known)
Doctor’s Name
Clinic Address
When did you last see your doctor?
MENTAL HEALTH & SUPPORT TEAM
Are you currently seeing a:
If yes, please provide practitioner name(s)
CONSULTATION GOALS
What would you like to achieve from your consultation? (Tick all that apply)

Other
MEDICAL HISTORY
Have you been diagnosed with any of the following conditions? (Tick all that apply)

Other
Please provide further details regarding your medical history
Please upload any relevant reports (optional)

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FEMALE HORMONAL HEALTH (If applicable)
Please select the option that best applies:
If using contraception, please specify type
INTEGRATIVE & COMPLEMENTARY HEALTH PRACTICES
Are you currently using or receiving any complementary, traditional or holistic therapies? (Tick all that apply)

Other
Please provide details of any treatments, practitioners or remedies currently used
MEDICATIONS & SUPPLEMENTS
Please list all current medications, supplements, vitamins and recent antibiotic use
EXERCISE & MOVEMENT
Please describe your current exercise routine in detail, including type, duration, frequency, rest days, and any sports supplements used
LIFESTYLE HABITS
Have you seen a Nutritionist or Dietitian before?
If yes, please provide details
Any dietary plan or modifications made – kindly share
Smoking Status
How many alcoholic drinks do you consume per week?
Daily water intake (approximate amount)
How many caffeinated drinks do you consume daily?
How many times per week do you consume sugary foods or beverages?
Lunch Habits
DIETARY INTAKE ASSESSMENT
Typical Weekday Eating Pattern (include meals, snacks, beverages and meal timing)
Typical Weekend Eating Pattern (include meals, snacks, beverages and meal timing)
FOOD PREFERENCES
Who does the grocery shopping and cooking in your household?
Favourite Foods
Foods you dislike or avoid
Previous diets or nutrition approaches tried (e.g., Weight Watchers, Keto/LCHF, Paleo, Intermittent Fasting, OA)
FOOD ALLERGIES & INTOLERANCES
Please list any diagnosed or suspected food allergies, intolerances or sensitivities
Have you ever experienced reactions to foods? (Tick all that apply)

Other
Please provide any additional digestive symptoms
DIGESTIVE HEALTH
Constipation
Diarrhoea
ENERGY, RECOVERY & WELLBEING
How would you rate your daily energy levels?
Do you experience any of the following regularly? (Tick all that apply)
SLEEP & STRESS
Average hours of sleep per night
How do you usually feel upon waking?

Other
Do you often feel stressed or overwhelmed?
LAB TESTING & HEALTH INSURANCE
Have you had blood work completed within the last 3 months?
Will you be claiming this consultation/package through health insurance?
READINESS & SUPPORT
What motivates you most to improve your health?
What do you think the problem is?
What challenges or barriers do you currently face?
What have you tried before to cope with similar situation/issue/concern?
What have you tried before to cope with similar situation/issue/concern?
What matters to you the most? Tick as many that matters Trust Respect Love Yourself Other's opinion Hope All of above Anything else:
Your commitment level – on the scale of 1 – 10 (1 means no confidence/ commitment and 10 means 100% committed)
Do you have support from family, friends or workplace?
ADDITIONAL COMMENTS
Please provide any additional information you would like your practitioner to know
CONSENT & DECLARATION
I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that withholding relevant medical or lifestyle information may affect the quality of nutritional advice provided. I acknowledge and agree to the clinic’s terms and conditions, including cancellation and late appointment policies.
MARKETING & COMMUNICATION CONSENT
Would you be comfortable receiving occasional nutrition updates, wellness tips, recipes, educational resources and clinic news from MNSV Consultant & Coach?
Client Signature
Date

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Date
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MNSV Consultant, Coach & Research Health Nutrition & Lifestyle Assessment Form

YOUR DETAILS

HEALTH & BODY COMPOSITION

MENTAL HEALTH & SUPPORT TEAM

CONSULTATION GOALS

MEDICAL HISTORY

FEMALE HORMONAL HEALTH (If applicable)

INTEGRATIVE & COMPLEMENTARY HEALTH PRACTICES

MEDICATIONS & SUPPLEMENTS

EXERCISE & MOVEMENT

LIFESTYLE HABITS

DIETARY INTAKE ASSESSMENT

FOOD PREFERENCES

FOOD ALLERGIES & INTOLERANCES

DIGESTIVE HEALTH

ENERGY, RECOVERY & WELLBEING

SLEEP & STRESS

LAB TESTING & HEALTH INSURANCE

READINESS & SUPPORT

ADDITIONAL COMMENTS

CONSENT & DECLARATION

MARKETING & COMMUNICATION CONSENT