Dear Client,

Thank you for choosing to work with us on improving your eating habits and nutritional intake. In order to get started, please follow the directions as carefully as possible:

Please answer all of the questions listed below, give the exact information requested and in the manner is which it is asked.  Be as complete and honest as possible. The more thorough your responses, the more complete your evaluation will be.

Okay, let’s get started…

PERSONAL INFORMATION
First Name:  _______________________       Last Name:  _________________________      Your age:  _________

Cell #_________________________        E-mail _________________________

Your gender:   male  female                Your Height:   ______

Your Weight: ______________ lbs.                    Your Occupation: ________________________________

MEDICAL INFORMATION

How would you describe your present state of health:
very well    healthy    unhealthy     ill        Other: ________________________________________

Are you taking any prescription medication?               yes          no
If yes, what medications and why?

_______________________________________

_______________________________________
Do you take any over the counter medication?            yes         no
If yes, what medications and why?
________________________________________

________________________________________

________________________________________

Have you ever had your cholesterol checked?   yes        no.             If yes, when: _________________________

What were the results:   Total cholesterol:_______________   HDL_____________   LDL____________   TG ____________

Please check any which apply to you and list any important information about your condition:

Chronic sinus condition     Allergies     Diabetes      Hypoglycemia       Insomnia
Skin problems        Asthma       Constipation     Blood pressure       Diarrhea     Ulcer
Intestinal problem     Arthritis      Major surgeries      Past injuries      PMS     Irritability  Depression     Menopausal  symptoms
Please describe any other health conditions you may have :
_____________________________________________________

_____________________________________________________

_____________________________________________________

FAMILY HISTORY

Has anyone in your immediate family been diagnosed with the following. Check all that apply.
Heart disease         If yes, what is the relation and the age diagnosed : _____________________________________
High cholesterol   If yes, what is the relation and the age diagnosed: ____________________________________
High blood pressure   If yes, what is the relation and the age diaagnosed:  ________________________________
Cancer   If yes, what is the relation and the age diagnosed:  ___________________________________________

DIET  HISTORY

What are your dietary goals?   ________________________________________________________________________
Have you ever followed a specific or modified diet?                   yes      no
If so, please describe:             _________________________________________________________________________

Are you currently following a special diet?                    yes            no
If so, what type of diet?    ____________________________________________________________________________

What do you consider to be the major issues in your diet and eating plan?   (i.e. Eating late at night, snacking high fat foods, desire for better health, desire for better physical performance, etc.)
__________________________________________________________________________________________________

__________________________________________________________________________________________________

How much water do you drink per day?  __________________     8 ounce glasses

Do you have any food allergies or intolerance?   yes   no   If so what?   ________________________________

Who prepares your food?  self   spouse   parent   minimal preparation

How often do you dine out?   _____________    times per week

Please specify the type of restaurants for each meal:
Breakfast:     _________________________                Lunch:          __________________________________
Dinner:         _________________________                Snacks:         __________________________________

HABITS

Do you crave any foods?         yes        no
If so, please specify:  __________________________________________________________________________

How is your appetite affected by stress?
increased       decreased        not affected

Do you drink alcohol?              yes       no
How often?   __________   times per week                  Average amount:  ____________    glasses

Do you smoke?   yes       no
How much (cigarettes, cigars, chewing tobacco per day?)  _________________

Do you take any vitamin/mineral supplements regularly?       yes      no
Please list type and amount per day:   _________________________________________________________________

Do you currently participate in any structured physical activity?   yes   no

If so, please describe:   _____________________________________________________________________________
______________   minutes cardiovascular activity,     _____________   times per week
______________   strength training sessions,            _____________   times per week
______________   minutes of flexibility,   per day      _____________   times per week
______________   minutes of sports per week            List sport(s)       _____________

WEIGHT HISTORY

What would you like to do with your weight?
lose weight            gain weight               maintain weight

What was your lowest weight within the last 5 years?     _____________  lbs.

What was your highest weight within the last 5 years?   _____________   lbs.

What do you consider to be your ideal weight?   ________________  lbs.      I don’t know

Your present weight:   _______________ lbs.

Body composition:   _____________  %body fat         I don’t know

What specific questions would you like to have addressed in the assessment?

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