Nutrition Assessment Form

Personal Details

Full Name: *

Date of Birth: *

Age: *

Contact Number: *

Email: *

Height and Weight History

Height (feet and inches): *

Current body weight (pounds): *

Desired body weight (pounds): *

Lowest body weight (pounds):

Year:

Highest body weight (pounds):

Year:

Nutrition and Fitness Goals

What are your nutrition and fitness goals? *

What have you tried in the past to achieve your nutrition and fitness goals? This includes any diet or exercise program, supplement use, books etc. *

Medical History

Are you currently taking any medications? *

Please specify: *

Do you have any allergies or intolerances? Please include all known allergies/intolerances regardless of whether they are food-related. *

Please specify: *

Have you ever had surgery? *

Please specify: *

Do you have any history of high cholesterol? *

Please specify: *

Do you have any history of diabetes? *

Please specify: *

Do you have any history of heart disease? *

Please specify: *

Do you have any history of hypo/hyperthyroidism? *

Please specify: *

Do you have any history of bowel disease (i.e. Crohn’s Disease, Ulcerative Colitis, Irritable Bowel Syndrome)? *

Please specify: *

Have you had any recent injuries? *

Please specify: *

Have you ever been diagnosed with an eating disorder? *

Please specify: *

Females Only

1. At what age did you get your first period?

2. Do you get regular periods?

3. When was your last menstrual period?

4. How long did it last?

5. Do you take any oral contraceptives?

Please specify:

Health Information

1. Do you take any vitamin or mineral supplements? *

Please specify: *

2. Do you take any type of nutritional supplements (i.e. protein shakes, powders, energy drinks etc.)? *

Please be specific and include brand names if known: *

3. Are there any foods that you avoid? *

Please specify the foods and your reasons for avoiding: *

4. Do you follow a certain diet (i.e. Vegetarian, Pescatarian, Vegan, Paleo, Keto etc.)? *

Please specify: *

5. Do you drink alcohol? *

On average, how many days a week do you consume alcohol? *

On average, how many units of alcohol do you consume in a week? *

What types of alcohol do you consume? *

6. Do you drink caffeinated beverages? *

Please list the caffeinated beverages you drink and how often you drink these: *

7. Do you smoke (tobacco products)? *

How many cigarettes per day? *

8. On average, how many hours do you sleep on weeknights? *

9. On average, how many hours do you sleep on weekends? *

10. Please rate your quality of sleep on a scale of 1(Bad) to 5(Excellent): *

11. Please rate your stress levels on a scale of 1(Bad) to 5(Excellent): *

12. How do you manage your stress? *

13. Have you seen a counselor/therapist in the past, or are you working with someone presently? *

Please specify: *

14. What is your daily water intake (fl oz)? *

Exercise Information

Do you do any exercise? *

Please specify what exercises/sport/training you typically do each day (please provide as much detail as possible):

Monday: *

Tuesday: *

Wednesday: *

Thursday: *

Friday: *

Saturday: *

Sunday: *

Are you currently working with a trainer or coach? *

What are the goals for these sessions and how often do they take place? *

Nutrition Log

Please list out what a typical day of eating looks like for you.

Please be very specific, including times, portion sizes and brands (i.e. 1 Latte made with whole milk, 45g Porridge oats etc…).

Do not forget to include drinks.

Breakfast

Time: *

Item(s): *

Morning Snack

Time: *

Item(s): *

Lunch

Time: *

Item(s): *

Afternoon Snack

Time: *

Item(s): *

Dinner

Time: *

Item(s): *

Evening Snack

Time: *

Item(s): *

Eating Habits

1. Do you follow a meal plan? *

Please specify: *

2. Do you prepare your own meals? *

3. Do you track your macronutrients (i.e. protein, fat, carbohydrates)? *

4. Where do you tend to shop for groceries? *

5. How often do you go out to eat? *

6. How often do you eat fast food / takeout? *

7. Do you have any concerns fitting in meals/snacks based on your current schedule? *

Please specify: *

Please use this box for any additional information you feel would be helpful: