– New Client Form – Name First Last Address Email PhonePreferred method of contact Date of Birth Height Current Body Weight Desired Body Weight: Lowest Body Weight Highest Body Weight Physician PhoneNUTRITION 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...What are the most important reasons for you to make this change?Who will benefit from you making these changes? How will they benefit?What, if any, are challenges that may make it hard for you to achieve your goals?MEDICAL HISTORY AND MEDICATIONS:Please list any relevant past medical history and current medications:Have you ever been diagnosed with an eating disorder? YES NO If Yes please listDo you take any Vitamin / Mineral supplements? YES NO If yes, please listAre there any foods that you avoid? YES NO If yes, please list belowAre you a Vegetarian? YES NO If yes, please choose which foods you DO NOT eatred meatchickenfishdairyeggsOn average, how many days a week do you consume alcoholic beverages?Please enter a number from 0 to 7.On average, how many alcoholic drinks do you consume at one time?Please enter a number from 0 to 20.What type of alcoholic drinks do you consume?BeerWineLiquorOtherWhat types of caffeinated beverages do you consume? I.e. energy drinks, coffee, tea, soda, etc.Do you smoke (tobacco products)? YES NO If yes, how many cigarettes per day?Please enter a number from 1 to 50.On average, about how many hours do you sleep?WeeknightsPlease enter a number from 0 to 24.WeekendsPlease enter a number from 0 to 24.Are you stressed? YES NO If yes, on a scale of 1-10 (1 being the least, 10 being the highest), how stressed are you?Please enter a number from 1 to 10.How do you manage your stress?Have you seen a counselor / therapist in the past, or are you working with someone presently?Are you currently on an exercise program? YES NO If so, what specifically are you doing each day?Have you ever played a sport? YES NO If yes, which sport(s), when, and how long?On a scale of 0 to 10, how IMPORTANT is it for you right now to change?(0 Being not at all Important, 10 Being Extremely Important)Please enter a number from 0 to 10.On a scale of 0 to 10, how CONFIDENT are you that you could make this change?(0 Being not at all Confident, 10 being Extremely Confident)Please enter a number from 0 to 10.
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