Nutrition Assessment

Please fill in this Nutrition Assessment as accurately and honestly as you can in order to help you and I achieve the best results.

Name

First Name

Last Name

Age

Date of Birth

YYYY

Current Occupation

Consult reason / main health concerns

Weight (kg)

Weight history

Height (cm)

List any recent and relevant blood test results

Medical history

Current medications

Allergies

Current nutrition supplements

How many times do you smoke per week?

What is the average number of hours of sleep you get per night?

Physical Activity

Level of stress experienced recently

Typical daily energy levels

Dieting history

Who prepares the majority of your meals currently

How many main meals do you usually have each day

List some of the most common foods you have for your meals and snacks

How many snacks do you usually have each day?

Average number of coffees per week?

Average number of soft drinks per week?

Average number of alcoholic beverages per week?

Average number of meals out / takeaways per week?

Nutrition / health goals

Weight goal (kg)

Main motivations for improving your health

Other comments or things you would like to share