Name

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.

– New Client Form –

NUTRITION AND FITNESS GOALS:

MEDICAL HISTORY AND MEDICATIONS:

Winter Lemon Roasted Potatoes

Nut Butter Bites

Anti-Inflammatory Trail Mix