Initial Assessment

Please fill out and submit this form to me at least 24 hours prior to our initial chat. Be sure to include a log of your daily meals beginning 5 days before we meet.

Name

Age

Height

Weight

Physical Activity

Allergies (food and non food; including intolerances)

Supplements

Medications

Alcohol Intake

Smoker?

Yes No

Caffeine Consumption

Water Intake

Briefly discuss your past nutrition and eating history:

List any non-negotiable food items that you must have:

Do you currently use my fitness pal or log your food intake per day?

Yes No

Number the following from 1-5 with 1 being the lowest and 5 being the highest.

Energy Level

Stress Level

Hunger Level

Sex Drive

Sleep

Are you usually in a good mood or a bad mood? Any triggers?

What are your 6 months goals you want to achieve working together?

Do you have any weight loss or weight gain goals?

Do you prefer texts or emails?

Text Email

What time do you wake up in the morning and what time do you go to bed?

If you participate in physical activity, what foods do you typically eat before and after a workout?

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Initial Assessment

Number the following from 1-5 with 1 being the lowest and 5 being the highest.

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