New Client Assessment Questionnaire

All fields are required.

    Personal Information

    Name

    Date

    Address

    Home #

    Email

    Office #

    Sex

    Cell #

    Weight

    Height

    Birthdate

    Age

    Health History

    1) What medical concerns (e.g., pregnancy), if any, do you have at the present time?

    2) Indicate if you have any of the following problems:

    3) Do you have complaints about any of the following?


    4) Family Health History:


    Mother:

    Father:

    Brothers:

    Sisters:

    Other:

    5) Do you smoke?

    If yes, how much?

    6) Do you enjoy physical activity?

    Explain:

    Activity Level:

    If you participate in regular physical activity, please complete the table below:

    List your activities

    How many times a week do you do this activity?

    How much time do you spend in this activity in a typical week?

    1)

    2)

    3)

    4)

    5)

    6)

    7)

    7) List any food allergies or intolerances.

    Drug History

    List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take.

    Diet History

    1) Do you follow a special dietary plan, such as low cholesterol, kosher, or vegetarian?

    2) Have you ever followed a special diet?

    Explain:

    3) Are there certain foods that you do not eat?

    4) Do you eat at regular times each day?

    How Often?

    5) Identify any foods you particularly like:

    6) Do you drink alcohol?

    YesNo

    How Often?

    7) What is your goal weight?

    Goal weight:

    8) What is your lowest adult weight?

    Lowest adult weight:

    Age at this weight?

    9) What is your highest adult weight?

    Highest adult weight:

    Age at this weight?

    10) Are you currently on a diet or taking prescribed or over-the-counter medication to lose weight or to maintain your current weight?

    If answer other than "No", describe the diet or list medications:

    11) If you have tried to lose weight in the past, please check all that apply

    Explain diet(s), medications and/or other:

    Did you lose weight?

    If yes,

    lbs over this period of time:

    How much of this weight, if any, did you gain back?

    lbs

    What worked best for you and why?

    12) What changes would you like to make?

    13) Please add any additional information you feel may be relevant to understanding your nutritional health.

    14) Who prepares most of the meals in the home?

    Shopping?

    15) Do you use convenience foods daily?

    16) How often do you eat out?

    Where?

    I have read, understand and accept the

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    Date Today: