Nutrition Consultation Form

*Please be as specific as possible. The more you let us know, the more we are better prepared to help you!

First Name *

Last Name *

Email *

Current Date *

What’s motivated you to seek nutritional counseling? *

What are your personal and/or health goals? *

Are you currently following a particular diet or nutrition plan? Please describe. *

When were you last at your desired weight? *

When was the last time you felt well/healthy? *

Any exercise routine or physical activity? How frequent are you physically active? *

What have you tried in the past to achieve nutritional goals? *

Do you believe you are over or under eating? *

Any medical history or conditions? Please list. *

Are you currently taking medications? Please list *

Do you have any food allergies? Please describe. *

Walk me through your day. (How many meals do you eat every day, do you eat outside, do you drink alcohol, do you use any tobacco products, what are your meals consist of, etc.) *