Nutrition Assessment Form

Full Name: *

Personal Details

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. *

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 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: *

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)? *

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: