Where to Start -

Where to Start

Diet & Lifestyle Assessment

We’re thrilled to embark on this journey to craft a delectable nutrition plan tailored exclusively for you, aligning with your unique needs and aspirations. To facilitate this process, kindly take a moment to complete the following form. Your input on your goals, usual dietary habits, lifestyle, and preferences is immensely valuable. We truly believe that there’s no such thing as “too much information” in this context. Your candid and comprehensive responses will pave the way for us to create a remarkable plan that you’ll wholeheartedly embrace. Rest assured, your trust is our utmost priority, and all information you share will be treated with the strictest confidentiality. ????

Full name ^*

Email Address ^*

Age ^*

Height ^*

Current Body Weight ^*

Ideal Body Weight ^*

Do you want to see changes in your body weight or composition? ^*

What are your health, lifestyle and dietary goals? ^*

Have you ever followed a diet, if so what was your experience? ^*

What do you hope to achieve working through a nutritionist ^*

Do you exercise regularly? ^*

” “Yes

” “No

If Yes, how often and what type of exercise? ^*

Do you feel your current diet is Healthy? ^*

” “Yes

” “No

If No, what do you think your current diet is lacking? ^*

Do you have any digestive issues? ^*

If Yes, what kind and how often? ^*

Do you have a bowel movement every day? ^*

” “Yes

” “No

If No, how often? ^*

Rate your daily energy on a scale of 0 to 10. ^*

How many times do you eat per day? ^*

Describe your typical Breakfast. ^*

What time do you eat Breakfast? ^*

Describe your typical Lunch. ^*

What time do you eat Lunch? ^*

Describe your typical Dinner. ^*

What time do you eat Dinner? ^*

Describe your typical Snacks. ^*

What times of the day do you eat Snacks? ^*

How many times a week do you eat out? ^*

” “None

” “1 to 2

” “1 to 3

” “4 or more

If you eat out, what is the most common meal you will eat out for? ^*

What is your motivation for seeking out a diet plan? ^*

Are there any food you will not eat due to sensitivites, allergies, or religious reasons? ^*

How much time would you want to spend in the kitchen per day? ^*

Which food prep style best describes you? ^*

” “I like to prep food in advance and eat the same meals for a few days.

” “I want to spend more time cooking and have different meal each day.

What are some of your favourite foods to eat? ^*

What excites you about having or following a custom diet plan? ^*

Is there anything that scares or intimidate you about following a custom diet plan? ^*

Is there anything else about yourself that you would like to share with me to help in building your diet plan? ^*

Contacts

Diet & Lifestyle Assessment

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