First & Last Name:

Email address:

Phone Number

What is your age, height, weight?

When is your ideal start date?

What are your primary health and nutrition goals? And why?

Include:

1. Short term goals (2-4 weeks)

2. Medium term goals (1-12 months)

3. Long term goals (1-5+ years)

Ask yourself why these goals are important to you and include your answer here too.

 Have you worked on your nutrition before? If yes, what have you tried and what did/didn't work?

Please list any current or previous medical conditions, diagnoses, hospitalizations or surgeries that may be relevant to your health.

 Please list all current medications and supplements.

 Have you been given any specific nutrition, fluid or supplement recommendations/restrictions by your healthcare team? If yes, please explain.

 Walk me through a typical day of eating and drinking, including meals, snacks and beverages.

 How would you describe your appetite?

 How much water do you typically drink each day?

 What are some foods and meals you really enjoy?

 Are there any foods you dislike or prefer not to eat?

 Do you have any food allergies, intolerances or dietary restrictions?

Do you regularly experience any digestive concerns?

Examples: constipation, diarrhea, bloating, reflux, nausea, abdominal discomfort, feeling full quickly, etc.

 How would you rate your current sleep from 1-10?

 How would you rate your current energy from 1-10?

 Describe your current activity/exercise routine.

 What do you feel are the biggest challenges with your nutrition right now?

 What do you feel you're already doing well?

 What tends to make it difficult for you to stay consistent with healthy habits?

What type of support do you think would be most helpful from me?

Examples: accountability, meal ideas, structure, education, specific weekly goals, troubleshooting, etc.

 Is there anything else you'd like me to know before we get started?