Nutrition Counseling Application
 

Please answer each question below. Your responses will help the dietitian better understand your nutritional goals and needs.

(*) Required Fields

 
Name: *
Phone Number: *
Email Address: *
Date of Birth: * Ex:1975
Current Height: *
Current Weight: *
Goal Weight (if applicable):
   
Reason for Visit: *
   
What do you expect to learn during nutrition counseling?
   
Do you participate in regular physical activity? No Yes (Please list below)
   
Physical Activities:
(List each activity, times per week,
and duration of activity)
   
On a scale of 0 to 10, select the number that shows how important it is for you to make lifestyle changes? (Lifestyle changes are changes to improve your health, such as changing your diet and increasing your physical activity.) 1 2 3 4 5 6 7 8 9 10
 Not Very Important     Somewhat Important     Very Important
   
What things might make it hard for you to make lifestyle changes?
   

On a scale of 0 to 10, select the number that shows your current level of stress.

1 2 3 4 5 6 7 8 9 10
 Very Relaxed              Managing OK               Very Stressed
   
What prescription medications, vitamins, supplements (including protein powders), performance enhancing supplements or herbal products are you currently taking and for what reason?
   

Please check to be sure you have answered all questions. Thank you very much!