Personal Information

Name: ___________________________________________

Age: _____________________________________________

Birth Date: ________________________________________

Height: _ ________________ Weight: _ ________________

Usual Weight: _ ______________

Weight History: (any exception gains or losses, etc) _ _______________________________

Do you have any other health concerns? _ _______________________________________________________________________

Are you taking any medication? No. Yes

Please List: _ ____________________________________________________________

___________________________________________________________________________

What are your goal(s) and expectations in meeting with a Nutrition Coach?

What do you see as being obstacles that could get in the way of you achieving your goals? Do you have a plan to deal with these?

Do you feel that you have a positive support system that will help you to stay on track with your goal? What do you feel you need for supports?

Do you have any food allergies, sensitivities or intolerances? No Yes

If yes, please list and describe the symptoms:

Lifestyle Information

Do you drink alcohol? No Yes # drinks/week

Do you smoke? Yes No # packs/day # years

Do you exercise? No Yes

What type and how many times per week?

Do you take any supplements/vitamins/minerals?

No Yes If yes, please list (include amount):

How many meals do you eat away from home each week?

Daily Food Log:

Meal	Day 1	Day 2	Day 3
Breakfast
Lunch
Dinner
AM Snack
PM Snack
Bed Time Snack
Water (# of cups)

Enter as much information as possible. Brand, quantity or portion size

Juice/pop: _____________ Water: _______________ Added salt: __________________ Yogurt: _____________ Cheese: _______________ Salty foods: __________________

Red Meat: _____________ Processed meats: _______________ Poultry: _____________ Nuts: _______________

Butter: __________________ Legumes: __________________ Time Meal