Nutrition Consultation Form

CLIENT INFORMATION:

Date

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(FN, M.I, LN)

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Occupation

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Age

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Religion

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Height (meters)

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0.00

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Weight (kg)

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BMI = 0.00

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BMI Category:

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Medical History:

Please check all options that are relevant.

Not Applicable

Cancer

Cardiovascular Disease

Diabetes

Kidney Disease

High Cholesterol

High Blood Pressure

Intestinal Problems

Others

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Family History:

Please check all options that are relevant.

Not Applicable

Cancer

Cardiovascular Disease

Diabetes

Kidney Disease

High Cholesterol

High Blood Pressure

Intestinal Problems

Others

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Pls Specify

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Pls Specify

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LIFESTYLE ASSESSMENT:

Are you currently being treated for any medical conditions?

Yes

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Please specify:

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Have you ever been advised by your physician to follow a special diet?

Yes

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Please specify:

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Do you have any food restrictions due to allergies, religion, etc.?

Yes

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Please specify:

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Do you skip meals?

Yes

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Do you snack?

Yes

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If yes, how many days a week do you eat:

Breakfast

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Lunch

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Dinner

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Who usually prepares the food at home?

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What foods do you crave?

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What foods do you avoid?

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What is your usual pattern for the evening meal?

Biggest meal

Medium size meal

Light meal

Seldom eat dinner

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How much water do you drink each day?

<1 cup

1-2 cups

3-5 cups

>6 cups

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Do you usually salt your food?

Always

Moderately

Sparingly

Never

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Do you take any other nutritional supplements?

Yes

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Please specify:

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Do you take any vitamin or mineral supplement?

Yes

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Please specify:

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List any medications you are currently taking:

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NUTRITION AND FITNESS GOALS:

What are your nutrition and fitness goals?

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What strategies have you previously attempted to achieve your nutrition and fitness goals? This includes any diet or exercise program, supplement use, books, etc.

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NUTRITION LOG:

What did you eat and drink yesterday? Please include portion sizes/brands if possible. I.e. 1 bottle of 250mL Minute Maid orange juice, 1 pack Skyflakes, 1 cup water, etc

Breakfast: Time:

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Item(s):

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Morning Snack: Time:

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Item(s):

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Lunch: Time:

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Item(s):

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Afternoon Snack: Time:

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Item(s):

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Dinner: Time:

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Item(s):

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Snack/Dessert: Time:

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Item(s):

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NUTRITION ASSESSMENT:

How would you describe your diet?

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Would you describe the amount of butter or margarine you usually spread on breads as?

none

light

moderate

generous

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When you eat meat, do you usually eat portions that are?

small

medium

large

never eat meat

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FREQUENCY

How often do you work out?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you bring packed lunch?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you eat out?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink alcohol?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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Do you smoke?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink alcohol?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink fruit juice?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Caffeinated coffee?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Regular soft drinks?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Decaffeinated coffee?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Regular tea?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Diet drinks/aids?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Iced/Milk tea?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Diet soft drinks?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you drink Sports drinks?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you eat fruits and vegetables?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How many times per week do you eat red meat, and what size is the usual portion size?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How many times per week do you eat poultry products, and what size is the usual portion size?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How many times per week do you eat fish and shellfish, and what size is the usual portion size?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you consume dairy products, and what type do you prefer?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you indulge in desserts and sweets?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How many times in a week do you eat chips, such as potato chips or corn chips?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How many eggs do you typically consume in a week?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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When you eat meat and there is visible fat, do you trim it off?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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Do you eat the skin on chicken and turkey or the fat on meat?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you consume processed meats (like bologna, salami, corned beef, hotdogs, sausage or bacon)?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you eat fried foods like fried chicken, fried fish or French fries?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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How often do you cook with oil, butter, or margarine instead of cooking without fat?

Please check the option that best applies to you:

Never (Not at all)

Sometimes (1 - 3 times per week)

Often (4 - 6 times per week)

Always (More than 7 times a week)

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Notes:

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Submit

CLIENT INFORMATION:

LIFESTYLE ASSESSMENT:

If yes, how many days a week do you eat:

NUTRITION AND FITNESS GOALS:

NUTRITION LOG:

NUTRITION ASSESSMENT:

FREQUENCY

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