Nutrition Client Profile
GoalsWhat is your main reason for nutrition consultation?What do you want to achieve from these sessions?
How can I help and support you to get the outcome you are after?To be encouraged when it is challengingMotivation to follow throughTo be held accountable for my actionsSupport to keep me on trackProfessional adviceBe provided with hand outs A planRegular contact I prefer to continue independentlyOther
Have you had professional dietary advice and/or support before?If so, what was the reason? Did you achieve your goal?
When was your last visit to your doctor (GP)?Within the last monthWithin the last 3 to 6 monthsWithin the last yearMore than one year agoDo you smoke?YesNo
Current weight (kg)
Lowest weight (kg) in your adult life (18 years+)
Heaviest weight (kg) in your adult life (18 years+)
In the last 3 months has your weight:IncreasedStayed about the same Decreased
What is your desirable weight (kg) range?
How would you rate your current sleep patterns?Excellent GoodFairPoor
How would you rate your current energy levels?ExcellentGoodFairPoorHow would you rate your current motivation to achieve goals?ExcellentGoodFairPoor
How would you rate your current general health?ExcellentGoodFairPoorHow would you rate your current stress level?Very stressedSomewhat stressedNeutralRelaxedWhat concerns do you have about your diet and your health?Please list any relevant medical history and current medications and/or SupplementsPlease list any relevant blood test resultsYour LifestyleIf you are currently exercising on a regular basis: Please explain:What TYPE, DURATION, and level of INTENSITY (1 is low 5 is high), and time of the day you generally do this.
Is your job mostly on your feet or sedentary?Mostly on my feetMostly sitting down Do you regularly travel out of town for your job?YesNo Daily mode of transportCarScooter / Motor BikeBusBikeWalkOtherWhat is your living situation at home?AloneFlattingWith parents With partner / Wife / HusbandBoardingOtherWho makes most of your meals?MeSomeone elseSharedWho does most of your food shopping?MeSomeone elseSharedDo you usually:Take food from home for the dayBuy food and drinks while you are outBothAre you currently following a special diet?Low carbohydrateHigh ProteinGluten-freeLow-fatVegetarianVeganCalorie controlledOtherPlease explain any cultural eating routines or belief around foodHave you changed your usual eating habits in the last two weeks?YesNoPlease list any food allergies or intolerances that have been diagnosed by a medical professional.Please indicate if you experience any unpleasant symptoms which may be attributable to your food intakeGasBloatingDiarrheaConstipationCramps or discomfortRefluxNo bowel movement for more than 2 daysNausea Describe your daily eating habits: What you would usually do as a part of your routine and why?
CommentsWhat is your typical eating environment?At homeIn the car / busOn the run from one place to anotherWhile standing Alone With peopleAt your deskWhile watching TV or on the computer
Approximately how many alcoholic drinks would you have in a week?Only occasionally1 - 2 per week3 - 5 per week6 - 9 per week More than 10 per weekI don't drink alcoholOn average, how many times would you eat out or buy fast food in a week?E.g. Cafe, Takeaways, Restaurant, Mall etc. 1 - 2 per week3 - 5 per weekEveryday Only occasionally I don't buy food when I am outPlease list any foods you love and you would prefer not to live without:Please list any foods you dislike and/or avoid:Please indicate if you are interested or would like more information on any of the following:7-day Meal plan12 Week on-going Programme supportDiet Nutritional Analysis and ReportSports Performance Plan for a race /eventCarbohydrate-loading plan for an endurance eventFollow-up consultations as necessaryI certify that the above information supplied by me is true and complete to the best of my knowledge
Date of Birth
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