Name

E-Mail

Phone Number

Height

Current Weight in LBS

BMI (if known)

Hemoglobin a1c

Triglycerides:

CHOLESTEROL:

HDLs:

LDLs:

When was your last checkup?:

How often do you weigh yourself?:

How do you feel about that weight?:

Any recent Diagnosis?: Any recent Diagnosis?: Yes No

If yes, please explain below:

Do you have food allergies?: Do you have food allergies?: Yes No

If yes, please explain below:

Current Medications and Dosages:

Do you take multi-vitamins or supplements:

Family history of illness:

Typical Breakfast

Typical Lunch

Typical Dinner

Typical Snacks

On average, How many meals do you eat a day?

When having a meal, when do you stop eating?

How much water do you drink daily?

What are your typical beverages?

What qualifies as dessert for you?

What fruits and vegetables do you like?

What fruits and vegetables do you not like?

What time is your first meal of the day?

Do you know correct portion sizes? Do you know correct portion sizes? Yes No

Is it necessary for you to have meat at each meal? Is it necessary for you to have meat at each meal? Yes No

What is your all time favorite meal:

What is your view/philosophy of food:

How often do you eat take out or fast food?

Describe your typical eating environment? (Examples: Alone, w/spouse, in the car, at your desk):

During your life time, please think about when you felt the most healthy and happy? What did you look like at the time?:

What changes have you recently made in eating?

What would you like to see in your meal plan?

What is a typical day like for you? Morning through evening:

Have you ever kept a food diary or journal? Have you ever kept a food diary or journal? Yes No

When you eat, do you ever feel guilty? When you eat, do you ever feel guilty? Yes No

Drink Alcohol? Drink Alcohol? Yes No

What?

How much?

How often?

Do you know how to read food labels? Do you know how to read food labels? Yes No

Do you exercise? Do you exercise? Yes No

**On a scale of 1-10 ( 1 being “not ready at all” and 10 being “more ready than I’ve ever been”), how would you rate your readiness for change your eating behavior?

1. What is/are your short term goal(s)?

2. What is/are your long term goal(s)?

3. What do you think is holding you back from this progress?

4. What have you tried previous to get you on track with food?

5. What is your primary goal for your nutrition consulting experience?