Nutrition Assessment form

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Personal Information

Gender:

Medical History 

Goals and readiness assessment 

 Your Health and Nutrition Goal 

Three Dietary Habits you Want to Change 

The biggest challenge(s) to reach your goals

Lifestyle and Diet History 

Physical Activity : 

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On Average How many Hours of Sleep do you get ? 

Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious or other) ?

Please list any food allergies, sensitivities or intolerances 

Which meal do you eat regularly? check all that apply. 

How often do you eat outside ? 

What are your favorite foods and beverages ? 

Food Dislikes : 

What do you eat and drink on a regular basis?

Please list any additional information you feel would be helpful for me to know. 

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