Date of Birth
Start with high school and list possible reasons for weight fluctuations
What are you currently doing for exercise?
How many hours do you sleep? Quality?
Allergies or Food Intolerances
Rank on 0-10 scale and list major causes
What vitamins, minerals, and protein powders, etc. do you take? List frequency and reason for use.
Have you ever had abnormal lab results? Any chronic conditions?
Family Medical History
Heart disease, cancer, stroke, diabetes, thyroid disorders, osteoperosis
Do you have a history of any abnormal eating behaviors? Under eating? Over eating?
Motivators & Goals
What is motivating you to seek nutrition counseling?
What are your short-term goals?
Within the next 16 weeks
What are your long-term goals?
What are your obstacles to living a healthier lifestyle?
Food & Beverage Intake
Who prepares meals in your home? For How many?
Who does the shopping? Where?
How many of your meals per week are home prepared?
How many days per week do you eat out?
Restaurants you most often frequent
Please list approximate quantity per day or per week
Please include as many details as possible: approximate times, quantities, brands, etc. It may be relevant to include a work day and a non-work day and/or a healthier day and a less healthy day.
Are there any foods you hate? Is it due to flavor, texture, temperature, color, fear, etc.? Think through different food categories: fruits, vegetables, meat, fish, beans, starches, nuts, seeds, dairy, etc.
Biggest food challenges and areas for improvement