Nutrition Consulting Agreement – Client Information

Please list all goals and questions that you have.(Required)

What are you hoping to gain from working together?(Required)

Please list any medical diagnoses you have received from a doctor.(Required)

Please list any past surgeries.(Required)

List any regular medications or supplements that you take regularly.(Required)

Please include any that may have been prescribed but you do not take.(Required)

Please list any recent labs that you have had done. Specifically include any that are out of range.(Required)

Do you have any food allergies, sensitivities, or intolerances?(Required)

Are you currently following any diet? Are there any foods that you restrict?(Required)

What, if any, diets have you followed in the past?(Required)

Do you skip meals? If so, which and how often?(Required)

On average, how many times a week do you eat out or order take-out?(Required)

On average, how many hours of sleep do you get per night?(Required)

On average, how many alcoholic drinks do you have per week?(Required)

On a scale from 1 to 10, how would you rate your relationship with food? 1 being poor and 10 being great.(Required)

On a scale from 1 to 10, how would you rate your energy through the day? 1 being low and 10 being consistent.(Required)

Rate your appetite. 1 being none/lots of cravings and 10 being hunger when waking and at meal times.(Required)

Rate your bowel movements. 1 being constipation/diarrhea and 10 being regular daily bowel movements.(Required)

On a scale from 1 to 10, how would you rate your concentration? 1 being brain fog/unable to concentrate and 10 being easily focused.(Required)

How would you rate your sleep? 1 being difficult to fall/stay asleep and 10 being easily stay asleep/stay asleep.(Required)

On a scale from 1 to 10, how would you rate your hair and nails? 1 being hair loss or thinning/brittle nails and 10 being healthy hair, skin, and nails.(Required)

How would you rate your ability to handle stress? 1 being anxious/easily overwhelmed and 10 being not a problem.(Required)

On a scale from 1 to 10, how would you rate your weight? 1 being inability to gain or lose/fluctuations and 10 being stable without effort.(Required)

How would you rate your mood? 1 being Irritable and 10 being stable.(Required)

Please describe your current physical activity routine.(Required)

Current Weight(Required)

Height(Required)

What do you do to fill your time? Please include hobbies, activities, and work.(Required)

After submitting this form, you will be redirected to the Nutrition Consulting Agreement. Please verify the information there and be sure to sign and submit the form.

Nutrition Consulting Agreement Client Information

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