Health & Nutrition Questionnaire

Please fill out this form before we meet for your Complimentary Initial Discovery Session.

Name

First Name

Last Name

Today's Date

YYYY

Referred By

Email Address

Phone Number

Birthdate

YYYY

Family/Living Situation:

Children

Occupation

Exercise / Recreation

What are your main health concerns that you’d like to address?

What is your biggest challenge(s) when it comes to your health concerns?

Tell me about your health history (including family health history)

Let’s talk about your diet in the last 3 months or so, what’s your typical breakfast, lunch, and dinner?

Do you have certain cravings? and when?

Do you have any food restrictions?

What was your diet and family eating habits like growing up?

Describe your diet at the onset of your health problem.

How was your diet changed in relationship to your health problems? (special diets?)

List any medicine or supplements you are currently taking for these problems:

Have you ever taken a course of antibiotics? When was your last course?

What are you looking for in a nutritionist? What are some needs that I can meet?

What are your health goals?

Tell Me About You