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Name
Age
Height
Email
Current weight
Phone number
Goal weight
Who referred you to the program? (if not by a person, list other source: facebook, instagram, google, etc.)
What is your occupation? Include the general level of activity this includes on a daily basis (desk job, on your feet, any heavy lifting etc).
Who do you see in your life currently as being your biggest supporters when it comes to pursuing better health?
Does your home environment have a supportive effect on your health?
Does your weight affect how you feel about yourself? If yes, please explain.
Have you ever had anyone hold you accountable to your nutrition related goals?
Yes
No
What are your specific health and fitness goals? What would make this time successful for you?
When are you aiming to achieve your goal?
Why is this goal significant to your life?
Please list and explain the three biggest challenges you face when it comes to nutrition and/or weight loss.
List any PAST medical concerns (high cholesterol, diabetes, heart disease, hypo/hypothyroidism, recent surgeries, bowl disease, depression, injuries, etc.):
List any CURRENT medical concerns (high cholesterol, diabetes, heart disease, hypo/hypothyroidism, recent surgeries, bowl disease, depression, injuries, etc.):
List the current medications you are on:
List any medications you have been on in the past:
If you have no diagnosed medical concerns, please list any symptoms you are currently experiencing (low energy, constipation, stomach pain, etc):
What have you tried in the past? This includes any diet or exercise program, supplement or books.
Please list any food allergies or intolerances:
What are the things you liked or disliked about those particular programs?
Do you have experience with Antibiotic use?
Never
Not much
More than 3x a year
Long term
Are you on birth control?
Yes
No
I have been on it in the past
Are there any foods that you avoid?
Yes
No
If yes, what foods do you avoid?
Do you currently take any vitamin/mineral supplements?
Yes
No
If yes, what supplements do you take?
Have you ever tried eliminating certain foods or food groups from your intake?
Yes
No
If yes, which ones and why?
What foods do you crave?
How often do you dine out weekly?
1 or 2 times
3 or 4 times
5 or 6+ times
Your meal most often eaten out:
Breakfast
Lunch
Dinner
Types of eating establishments most often visited (name of specific places or cuisine):
What is your overall level of exercise?
Little or no exercise
Light exercise 1-3 days a week (walking, jogging, hiking)
Moderate or intense exercise 5+ days a week
Hard exercise 6+ days a week
Please note any problems that limit your physical activity.
How many caffeinated beverages do you consume daily?
0
1
2
3
4
5
6
7
What time of the day do you feel most hungry?
Morning
Afternoon
Evening
Please explain your workout routine in more detail (the exercises you do, duration of the workout, strength training or cardio, combination, etc.)
Do you smoke tobacco products?
Yes
No
How many days do you consume alcohol?
0
1
2
3
4
5
6
7
What does a typical day look like for you? (please include the time you wake up and go to sleep and all activities in-between)
How would you rate your quality of sleep?
1 - very poor
2
3
4
5
6
7
8
9
10 - high quality
Do you have troubles falling asleep?
Yes
No
How would you rate your level of stress?
1 - no stress
2
3
4
5
6
7
8
9
10 - extreme stress
How do you handle stress? What relaxes you?
What eating habits would you like to change?
What eating habits are you most pleased with?
Have you ever been diagnosed with an eating disorder?
Yes
No
Maybe
Check all that apply to you:
Fast eater
Erratic eater
Emotional eater (stressed, bored, sad, happy etc.)
Late night eater
Dislike most "healthy food"
Travel frequently
Turn to convenience foods
Find it difficult to eat healthy with family
Find it difficult to eat with friends
Love to eat
Overeat often
Eat because I have to
Negative relationship with food
Confused about food and nutrition
Eat fast food often
Struggle at typically the same times each day
Binge every so often
Scared to eat sweets or desserts (treat foods)
Love to cook
Live or often eat alone
I sometimes feel food is more powerful than I am
Drink too much alcohol
I feel defeated and discouraged about issues related to weight or food
Eat too much processed foods (breads, pasta, chips)
Do not plan meals or menus
I say negative things to myself ("I'm so fat," "I'm not attractive," "I can't get my act together")
I feel guilty or embarrassed about what I eat or the size of my portions
I choose poor snack choices
I think about food way too much
The thought of changing how I eat makes me feel sad
I have gained and lost weight several times
When it comes to food and weight, I feel like I am trapped in a vicious cycle with no way out
I sometimes eat in secret or hide food
Past diet plans have made me feel deprived
What do you believe is getting in the way of your self-care?
What are you hoping to learn from our time together?
What words or phrases would you use to describe the kind of plan you think might be realistic for you over the long-term?
What is your biggest fear about choosing to follow a nutrition program?
Client Narrative: Please write a summary of any information that will be helpful to me regarding your health and medical history or in your own words, tell me your story.
I usually eat breakfast around:
6 AM
7 AM
8 AM
9 AM
10 AM
11 AM
Noon
I don't usually eat breakfast
One breakfast I often eat is:
Another breakfast I sometimes eat is:
I usually eat lunch around:
11 AM
12
1 PM
2 PM
3 PM
I don't usually eat lunch
One of the lunches I often eat is:
Another lunch I sometimes eat is:
I usually eat dinner around:
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM or later
I usually don't eat dinner
One of the dinners I often eat is:
Another dinner I sometimes eat is:
The snacks I often eat between meals are:
What might it cost you if you don’t significantly improve your lifestyle and underlying contributing factors to compromised health? (for example, vitality, longevity, joy, happiness, peace of mind, future physical independence, current and/or future relationships, career effectiveness, etc.)
What is your present level of commitment to change any underlying causes of your signs and symptoms which relate to your lifestyle? (rate from 0 to 10 with a 10 = 100% committed)
0
1
2
3
4
5
6
7
8
9
10 - 100% commited
Acknowledgment of Financial Policy - I understand the following policy: I am responsible for the total payment of my program, including a program payment plan, after the first counseling session is completed. Subscription cancellations or program holds are not permitted.
I understand and agree to these terms
SUBMIT
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