Nutrition & Lifestyle Assessment

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

When is your birthday?

What is your height (feet/inches) and current weight (lbs)?

Have you had weight changes within the last year?

Prior to the last year has your weight been stable (within 5 lbs)?

Yes
No

Current measurements *

Bust: Measure at the fullest part of your chest. Stand naturally with your heels together and arms resting by the side of your body. Position the tape so that it covers the widest part of the back, around the shoulder blades, under the armpits and over the fullest part of the chest.

Waist: Place your hand at your natural waistline and position the tape here. If you cannot find your natural waist, stand with feet slightly apart and bend to the side. Your natural waist is where your waist will crease.

Hips: Stand naturally with your heels together in a relaxed pose. Measure with the tape around the fullest part of the hips. Do not pull the tape tight.

Please list any known allergies (including non-food allergies) *

Please list any past medical history (even if not considered nutritionally relevant) *

Have you tried any “fad” diets in the past? If so, please list.

Do you follow a “special” diet now? If so, please list plan, program, or any restrictions followed.

How often do you eat outside your home? Please list frequented restaurants/eateries. *

Who is responsible for grocery shopping in your home? *

What is your average caffeine intake (estimated by 8 oz cups per day)? *

Do you find yourself craving specific foods? If so, please list. *

What is your average alcohol intake per week? Please specify if drinking beer, wine, or liquor. *

Please complete a three day food record that includes two week days and one weekend day. Be as detailed as possible. *

Select the one that applies: *

Trying to conceive
Pregnant
Breastfeeding
Not currently pregnant, TTC or breastfeeding

Are you currently exercising? *

Yes
No

How often per week and for what duration of time? *

What kind of workout equipment do you have access to?

What type of physical activities do you enjoy?

Do you have a gym membership or take classes? *

Yes
No

Where do you have a gym membership or take classes?

Please list all current or previous injuries. *

What is your occupation? *

Nutrition Lifestyle Assessment

The Assessment

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