– New Client Form –

Name
First Last
Address
Email
Phone
Preferred method of contact
Date of Birth
Height
Current Body Weight
Desired Body Weight:
Lowest Body Weight
Highest Body Weight
Physician
Phone
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...
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 list
Do you take any Vitamin / Mineral supplements?
- YES
- NO
If yes, please list
Are there any foods that you avoid?
- YES
- NO
If yes, please list below
Are you a Vegetarian?
- YES
- NO
If yes, please choose which foods you DO NOT eat
On 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?
What 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?
Weeknights
Please enter a number from 0 to 24.
Weekends
Please 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.

Contact Me

Looking to optimize your diet and support your body for optimal wellbeing? Whether you are new to nutrition or more advanced, let Growing the Seed be there for you. We take a personalized approach to nutrition and lifestyle. Together we will work to find the nutrition plan that supports you to be the best you possible. Call today for a complimentary introductory session and see what we can do for you!