. . . a holistic approach
where the whole person is the focus —
your spirituality,relationships, career and
physical activity are considered along
with nutritional values and balance
home
•
about me
• my approach •
your program
•
resources
•
links
•
contact
•
blog
Please Complete this Nutrition Assessment
Contact Information
Name:
Age:
Today's Date:
Telephone:
E-Mail:
Reason for Consultation:
Prior Nutritional Consultation?
Yes
No
If yes, are you currently following a particular diet or nutrition program? Please describe:
Health Summary
Medical History (e.g. heart disease, asthma, hypertension, cancer, IBS, dibetes, smoker? etc:
Women, check all that apply:
Regular Periods
Painful Periods
PMS
Fertility Concerns
Post-Menopausal
Describe:
Allergies:
Physical Limitations:
Physical Symptoms:
Rate your Digestive Function:
Good
Fair
Poor
Comment:
Rate your Energy Level:
Good
Fair
Poor
Comment:
Recent Labs (if known):
Family History (if known):
Medications (name/brand, dosage, frequency):
Vitamins/Minerals (name/brand, doosage, frequency):
Herbs/Botanicals (name/brand, dosage, frequency):
Other:
Height:
Weight:
Weight 6 months ago:
Weight 1 year ago:
Highest adult weight:
Desired Weight:
Do you have a history of eating disorders?
Yes
No
Comment:
How long do you sleep at night:
more than 8 hours
6 - 8 hours
less than 6 hours
Comment:
Exercise/Movement Type:
How often do you exercise?
What do you do to nourish yourself (have fun)?
What are you social/relationship concerns?
What are life stressors?
What healing arts/therapies do you practice on a regular basis?
What are your food concerns?
Do you do the grocery shopping?
Yes
No
Do you do cook?
Yes
No
What percentage of the food you eat is cooked at home:
Where do you eat out:
List your personal barriers/challenges to eating well:
Your Typical Day
Please indicate the time of day, what you eat and note if you usually skip a particular meal.
Breakfast:
Lunch:
Supper:
Snacks:
Typical beverages:
Are there any other things you would like to mention?