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Name
Age
18-24
25-34
35-44
45-54
55-64
65+
Contact information
Email Address
Phone
Occupation
Height
Weight
Any past Or current medical conditions (e.g. diabetes, hypertension, heart disease, thyroid, etc)
High Blood pressure
Diabetes
Heart Disease
Obesity
High Cholesterol
Irritable Bowel Syndrome
Celiac Disease
Anemia
Osteoperosis
Fatty Liver Disease
Chronic Inflammation
Constipation
Other (please specify)
Any surgeries or hospitalizations. Include year of event.
List any food intolerances, allergies, or dislikes.
Peanut Allergy
Tree Nut Allergy
Milk or Dairy Allergy
Egg Allergy
Wheat Allergy
Soy Allergy
Fish Allergy
Shellfish Allergy
Other (please specify)
List prescribed medications and what they are for.
List any supplements currently taking.
Multivitamins
Vitamin D
Vitamin C
Vitamin B Complex
Calcium
Omega 3 Fatty Acids
Probiotics
Protein Powder
Creatine
Callagen
Zinc
Coenzyme Q10
Fiber
Melatonin
Ginkgo Biloba
Echinacea
Other (please specify)
Typical daily Breakfast
Typical daily Lunch
Typical daily Dinner
Daily Snacks and Beverages consumed
Any specific dietary Restrictions and Preferances (e.g. vegetarian, gluten free, included culinary styles such as Asian, mediteranean)
Vegetarian
Vegan
Gluten Free
Dairy Free
Nut Free
Soy Free
Halal
Kosher
Low Carb or KETO
Paleo
Pescatarian
Intermittent Fasting
Sugar Free
Plant Based
Mediterranean
Other (please specify)
Weekly frequency of eating out or consuming processed foods_
Once a month - Special treat alert””
Twice a Month - Date night tradition
Once a week - Weekly escape from cooking”
Twice a week - The chef needs a break
Three times a week - More restaurant rewards points, please!!
Four times a week - Who has time to cook
Every Day - I don’t even know where my kitchen is
Never - My kitchen is my kingdom
How much water do you typically drink in a day
None - Does coffee count as water
1 to 2 Cups - Just enough to keep me alive!
3 to 4 Cups - Hydration on a budget
5 to 6 Cups - Halfway to a camel
7 to 8 Cups - Practically a hydration Hero
9 to 10 Cups - Water is my middle name
More than 10 Cups - Part Fish, Part Human
I don't count, I just drink
Do you consume any other beverages daily
Coffee
Tea
Sodas
Juice
Beer or Wine
Alcoholic beverages
Other (please specify)
Types of physical activity performed
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Cardio classes
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Weights
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Yoga
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Walking
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Running
No more than 1 time per week
1 to 2 times per week
About 3 times per week
4 or 5 times per week
Every day
Never
Duration of physical activities each time
Less than 20 minutes
20 minutes
30 minutes
45 minutes
60 minutes
Mote than 60 minutes
Average hours of sleep per night
Running on Fumes and Caffeine! (Less than 4 hrs)
Sleep? Who needs it? (5-6 hrs)
Well-Rested and Ready to Conquer! (7-8 hrs)
Sleep is my Superpower! (9-10 hrs)
I’m Practically Hibernatine (11+ hrs)
Quality of sleep from left to right, 1 to 10 stars with 1 being less and 10 more.
1 star
2 stars
3 stars
4 stars
5 stars
6 stars
7 stars
8 stars
9 stars
10 stars
STRESS Level from left to right, 1 to 10 stars with 1 being less and 10 more.
1 star
2 stars
3 stars
4 stars
5 stars
6 stars
7 stars
8 stars
9 stars
10 stars
Any stress reduction techniques you are currently practicing
What are your primary health and nutrition goals
Weight Loss
Weight Gain
Improving Heart Health
Increasing Energy Levels
Building Muscle
Improving Digestion
Enhancing Mental Clarity
Reducing Inflammation
Managing Blood Sugar Levels
Enhancing Athletic Performance
Reducing Stress
Healthy Aging
Supporting Bone Health
Balancing Hormones
Increasing Fiber Intake
Detoxifying the Body
Other (please specify)
Are there any specific challenges or obstacles you have encountered in achieving these goals
Time Constraints
Lack of Cooking Skill
Limited Access to Healthy Foods
Cost of Healthy Eating
Inconsistent Meal Planning
Portion Control
Cravings and Emotional Eating
Social Influences
Limited Variety
Understanding Nutritional Information
Dietary Restrictions
Motivation
Balancing Macros and Calories
Dining out or Travel
Food Allergies and Intolerances
Lack of Support
Stress and Fatigue
Mindset and Perception
Other (please specify)
How motivated are you to make changes to improve your health and nutrition habits
0
100
Clear
Are there any other factors or concerns that you would like to discuss during our consultation
Which diets have you tried in the past and how would you rank them
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
Intermittent Fasting
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
KETO Diet
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
Paleo Diet
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
Mediterranean Diet
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
DASH Diet
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
Flexitarian Diet
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
I just try to watch what I eat
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing
OTHER
Total Dumpster Fire
Rocky Road
Smooth Ride
Cruise Control
Smooth Sailing