Skip to Main Content
Use tab to navigate through the menu items.
Thank you for choosing me to be your guide! Please take a few minutes to fill out this comprehensive health assessment. After you submit your assessment, you will be directed to the following page to schedule your appointments.
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).
Does your weight affect how you feel about yourself? If yes, please explain.
Who do you see in your life currently as being your biggest supporters when it comes to pursuing better health?
Have you ever had anyone hold you accountable to your nutrition related goals?
What are your specific health and fitness goals?
When are you aiming to achieve your goal?
Why is this goal significant to your life?
Please list the three biggest challenges you face when it comes to nutrition.
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 past medications you have been on:
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.
What are the things you liked or disliked about those particular programs?
Please list any food allergies or intolerances:
Do you have experience with Antibiotic use?
More than 3x a year
Are there any foods that you avoid?
Do you currently take any vitamin/mineral supplements?
Have you ever tried eliminating certain foods or food groups from your intake?
What foods do you crave?
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?
Are you on birth control?
I have been on it in the past
If yes, what foods do you avoid?
If yes, what supplements do you take?
If yes, which ones and why?
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:
What time of the day do you feel most hungry?
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?
How many days do you consume alcohol?
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
10 - high quality
Do you have troubles falling asleep?
How would you rate your level of stress?
1 - no stress
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?
Check all that apply to you:
Emotional eater (stressed, bored, sad, happy etc.)
Late night eater
Dislike most "healthy food"
Turn to convenience foods
Find it difficult to eat healthy with family
Find it difficult to eat with friends
Love to eat
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:
I don't usually eat breakfast
One breakfast I often eat is:
Another breakfast I sometimes eat is:
I usually eat lunch around:
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:
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:
All programs (including payment plans) are non-refundable after the first initial counseling session.
I agree to these terms