Nutrition and Lifestyle Assessment - Initial Consultation - StacieGavin
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Nutrition and Lifestyle Assessment - Initial Consultation
Nutrition and Lifestyle Assessment- Initial Consultation
First and Last Initial
Date of birth
Height and weight
Names and ages of children (if applicable)
Names and type of pets (if applicable)
What are your goals? Health, lifestyle, occupation, relationships, etc.
What are your top 3 health concerns?
When did you start experiencing these concerns?
How have you dealt with these concerns in the past? (Doctors, alternative remedies, self-care)
Do any other family members have the same health concerns? Please explain
What other health professionals are you seeing now?
How often have you taken antibiotics?
Do you suffer from or are you concerned about any of the following?
High Blood Pressure
List typical foods you consume now ( the good, bad and the ugly)
Have you tried to lose weight before? If so, what have you tried?
Are there any foods that you avoid because of the way they make you feel? Please describe
What is your biggest challenge with eating healthfully?
What are the foods you crave the most?
Do you have any known food allergies or sensitivities?
Which of the following do you consume regularly? check all that apply
gluten (wheat, barley, rye)
dairy (milk, cheese, yogurt
Are you following a special diet or lifestyle plan? If yes, please explain
What percentage of your meals are home-cooked?
Please list all supplements and medications that you are currently taking?
How often do you exercise and what type?
How do you see a Health Coach helping you? (check all that apply)
Healthful food sources
Eating healthy while traveling
Kitchen food overhaul
How to cook
Learning which foods to avoid
Dining out strategies
Detox and Cleanses
Helping a family member
Fueling for fitness
Learning what to eat
Affordable health foods
Who is your biggest supporter for lifestyle changes? Who is your biggest critic?
At what point in your life did you feel your best? Why?
For women only: men and children may skip to the bottom
When was your last menstral cycle?
Menstral symptoms (check all that apply)
pain and cramping
Do you experience any yeast infections or urinary tract infections? If yes, how often?
Have you/do you take birth control pills? If so, what length of time and type.
Have you had any problems with conception or pregnancy?
Are you taking any hormone replacement therapy or hormonal herbs? Please list