Nutrition Client Profile

Goals

What 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 challenging
Motivation to follow through
To be held accountable for my actions
Support to keep me on track
Professional advice
Be provided with hand outs
A plan
Regular contact
I prefer to continue independently
Other

Have you had professional dietary advice and/or support before?
If so, what was the reason? Did you achieve your goal?

Your Health

Gender

Ethnicity

NZ European
Maori
Pacific
Asian
Other

When was your last visit to your doctor (GP)?

Within the last month
Within the last 3 to 6 months
Within the last year
More than one year ago

Do you smoke?

Yes
No

Height (cm)

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:
Increased
Stayed about the same
Decreased

What is your desirable weight (kg) range?

How would you rate your current sleep patterns?
Excellent
Good
Fair
Poor

How would you rate your current energy levels?
Excellent
Good
Fair
Poor

How would you rate your current motivation to achieve goals?
Excellent
Good
Fair
Poor

How would you rate your current general health?
Excellent
Good
Fair
Poor

How would you rate your current stress level?
Very stressed
Somewhat stressed
Neutral
Relaxed

What concerns do you have about your diet and your health?


Please list any relevant medical history and current medications and/or Supplements


Please list any relevant blood test results


Your Lifestyle

If 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.

Occupation

Is your job mostly on your feet or sedentary?
Mostly on my feet
Mostly sitting down 

Do you regularly travel out of town for your job?
Yes
No

Daily mode of transport
Car
Scooter / Motor Bike
Bus
Bike
Walk
Other

What is your living situation at home?
Alone
Flatting
With parents
With partner / Wife / Husband
Boarding
Other

Who makes most of your meals?
Me
Someone else
Shared

Who does most of your food shopping?
Me
Someone else
Shared

Do you usually:
Take food from home for the day
Buy food and drinks while you are out
Both

Are you currently following a special diet?
Low carbohydrate
High Protein
Gluten-free
Low-fat
Vegetarian
Vegan
Calorie controlled
Other

Please explain any cultural eating routines or belief around food


Have you changed your usual eating habits in the last two weeks?
Yes
No

Please 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 intake
Gas
Bloating
Diarrhea
Constipation
Cramps or discomfort
Reflux
No bowel movement for more than 2 days
Nausea

Describe your daily eating habits:
What you would usually do as a part of your routine and why?

Morning:

Mid-morning

Mid-day

Afternoon

Evening

Comments


What is your typical eating environment?
At home
In the car / bus
On the run from one place to another
While standing
Alone
With people
At your desk
While watching TV or on the computer

Approximately how many alcoholic drinks would you have in a week?
Only occasionally
1 - 2 per week
3 - 5 per week
6 - 9 per week
More than 10 per week
I don't drink alcohol

On 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 week
3 - 5 per week
Everyday
Only occasionally
I don't buy food when I am out

Please 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 plan
12 Week on-going Programme support
Diet Nutritional Analysis and Report
Sports Performance Plan for a race /event
Carbohydrate-loading plan for an endurance event
Follow-up consultations as necessary

I certify that the above information supplied by me is true and complete to the best of my knowledge 

Name

Date of Birth

Phone

Mobile number

Email address