Name
*
First Name
Last Name
Age/Height/Current Weight *
Email Address
*
Subject *
Do you know how many calories you are taking in a day?
Yes!
Most of the time
A rough estimate
Only when I log my food
Not a clue
How many alcoholic beverages drinks do you consume on a weekly basis?
0
1-3
4-7
8-10
+12
Do you have any dietary restrictions?
None
Vegetarian
Vegan
Pescatarian
Gluten-free
Lactose-intolerant
Other
Do you grocery shop weekly?
Yes! Multiple times a week!
Sometimes, depends on how busy the week is.
Never
Work provides me with meals
Other
What are your 3 go-to meals?
(Examples: breakfast tacos, crockpot chili, Hazel's sandwich. It's okay if they are home-cooked, ordered, or store bought! )
What are some of the issues you struggle with when it comes to nutrition?
(Examples: Portion size, Night time snacking, Lack of time, Drunken fast food, etc.)
Explain your past /current relationship with cooking. Do you enjoy it? Do you cook for yourself or others in your household?
Explain your past/current relationship with food.
(Examples: I don’t have time to eat so food annoys me, I can’t say no to trying new restaurants, food stresses me out, food makes me feel emotional, food makes me happy)
What would you like to achieve when it comes to nutrition?
Will friends and family be supportive of this commitment to your healthy lifestyle?
Reflect on when you felt the best about your overall health and body image. How old were you? Why did you feel that way? What things were you doing at the time that made you happy?
