Online Nutrition Assessment Questionnaire

Please complete and submit this form prior to your first Nutrition Counseling appointment.

All information contained herewith will remain confidential. I estimate that it will take you approximately 15 minutes to complete it.

Items that are required are marked with an asterisk(*).

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Phone

Date Of Birth

Height and weight (if known)

What is the main reason for your appointment, your main nutritional concern?

What have you tried in the past to help with your nutritional concern, and how did it work for you?

Type of diet you follow, if you follow a special diet:

If you exercise, please describe your exercise regime:

Please choose any health issues that apply to you:

• Obesity
• Diabetes
• Heart Disease
• High Blood Pressure
• PCOS
• Food Allergies
• Binge Eating
• Anorexia
• Hypothyroid
• Irritable Bowel
• Constipation
• Diarrhea
• High Triglycerides
• Depression
• Migraine or frequent headache
• Food allergies or sensitivities
• Tinnitus
• Joint pain
• Sleep disturbance
• Difficulty losing weight
• Brain fog
• Fatigue
• Rash or hives

Please list concerns not listed above:

Please list any medicines and supplements:

Please list any significant blood work results:

If weight loss is your goal, what obstacles have you encountered?

Who does the shopping and cooking in your household?

How many meals per day, including lunch and dinner, do you eat out?

Please list what you typically eat in the course of the day and timing:

Please share any additional information you would like me to know prior to your appointment:

Client agrees to a 24 hour cancellation policy to avoid being charged for the appointment: *

• Yes

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