Hey there! Congratulations on taking this step. To make the most out of our time together during our Nutrition Consult, please take time to answer the questions below in detail. I look forward to our session!!

Name

First Name

Last Name

Email Address

Do you shop more for convenience or budget?

Phone

Do you like to cook?

On a scale of 1-10, how would you rate your current nutrition?

List 3 beverages that you drink dally

What do you struggle with most when it comes to your nutrition?

What is your favorite comfort food?

Favorite vegetable:

Least favorite?

Favorite carbohydrate:

Favorite protein:

Typical time first meal of the day is eaten:

Typical time of the day kitchen closes at night:

What do you typically snack on?

Please list any current medications.

What is your primary health goal?

weight loss

weight gain

improved sleep

increased energy

improved overall health

What have you done in the past to work on this area? (include both alternative and traditional modalities)

What has proven effective?

What would you like your health to be like 6 weeks from now? How about 6 months? How would you feel if you got this result?

Meals most often shared with family:

breakfast

lunch

dinner

How often do you drink alcohol?

How much water do you drink each day?

How often do you read for pleasure or personal growth?

My current job is

Share a food journal, outlining a "day in the life." (Please be specific! List standard breakfast, lunch, dinner, snacks, as well as the times you eat.)

Are there any special dietary considerations that need to be made when designing your meal plan?

What are 5 things you LOVE about your life?

Please include anything else you would like to share!