Nutrition
Consultation Form
(This form only needs to be filled out once unless updating information) 

CONTACT INFO

How did you hear about our services?
Are you under the care of a medical doctor?
Recent surgical procedure?
Tobacco/Nicotine use?
Alcohol use?
Soda/Soft drinks?
Sweetended drinks/ice cream/smoothie bowls?
Hours of Sleep?
Physical demands of job?
What is general stress level?
Were you overweight as a child/teen?
During the day do you...
What type of groceries do you normally eat?
How often do you eat fast food/restaurant food?
How often do you cook your own food from whole/fresh ingredients
Dietary Restrictions (please check ALL that apply):
Digestive Discorders (please check ALL that apply):
How many times a day do you eat?
What do you crave most?
Do you skip meals?
Do you eat late at night?
Do you know how many calories you eat in a day?
Do you feel your energy level drop during the day?
Besides hunger, what other reasons cause you to eat?
Do you eat past the point of fullness?
Do you feel guilty about leaving food on your plate?
Do you eat foods high in fat/sugar?
Do you eat when you are NOT hungry?
How often do you exercise?
Do you have an appointment date yet?