Nutrition Pre Assessment

Please complete this pre assessment questionnaire to the best of your ability. During your initial consult, we will further discuss your health and wellness patterns in order to tailor a specific plan to meet your individual nutrition goals. All responses are confidential.

Demographics

Full Name:

Date of Birth:

Gender:

Address:

Telephone:

Email address:

Height:

Current Weight:

Occupation:

What is the main reason you are seeking nutritional counseling?

Medical History

List any current medical conditions that you are being treated for:

List any medications (over the counter or prescription) you are currently taking:

Name/Description

Dosage/Quantity

Frequency

Start Date

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