03 March 2020 Nutrition Assessment : Online This form is to understand your diet in order to better help you. Please answer the questions when applicable. If not, please skip the question.* RequiredName*Email address *Blood TypeSelect Blood TypeO+O-A+A-B+B-AB+AB-Telephone number* Area Code - Phone Number Weight*Height *Do you have any IntolerancesNoEggsDairyGlutenMedicationsBeansotherDate of birth *01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940daymonthyearDo you have any medical issues ? if yes please provide detailsHigh cholestrolHypetensionDiabetesotherMedicationsGoal Weight*Number of Kids (if you are a mother)Select value0123455+Date of Last Delivery (if you are a mother)01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940daymonthyearPlease indicate the breakfast you would have on a typical week dayPlease indicate the snack after breakfast you have on a typical week dayFruitsBiscuitsVegetablesChocolateI do not have snacksTeaotherWhat do you do between breakfast and lunch on a typical day?WorkHomeErrandsotherPlease indicate your lunch on a typical week day*Home made foodBurger outside homeSandwiches outside homeSalad outside homeI skip lunchFriesSodaJuiceotherPlease indicate the snack after lunch on a typical week day FruitsBiscuitsVegetablesChocolateI do not have snacksTeaotherPlease indicate your dinner on a typical week day *Take outHome made sandwichSame food from lunchI eat out most daysI do not have dinnerSodaFriesJuiceSandwichesPastaPizzaotherDo you have dessert every day YesNoAlmost every dayHow much water do you drink per day?Half a liter1 liter2 or more litersHow often per week does child consume the following? 01/week2/week3/week4/weekEvery dayFish*Chicken*Meat *Fruits *Nuts*Chocolate/Dessert *What types of food do you not consume and completely dislike? What is your favorite food? Who cooks in your home?MyselfSpouseFamily MemberChef or HelperNo cooking, mainly take outHow often do you exercise per day?0-30 minutes30 minutes-1 hour1-2 hoursNo time at allNone but willing to exercise for 30 minutes 3 times a weekNone but capable of exercising 1 hour 3 times a week or moreWhat is the reason you feel you are not losing weight? Or gaining weight (depending on your goal) I have many unhealthy snacksI eat large portions and don't stop when I feel fullMy food choices are often not healthyI have no schedule and my day is messyI eat well but I am not seeing resultsI love food too muchNo time to cookI eat when I am boredI eat when I am stressedI eat at nightWhen I see food I eat itotherHave you tried any diets before and have you been to a dietitian? I have never been to a dietitianI have been to a dietitian beforeI have tried several diets mysef and they did not workotherPlease mention your main concerns and all questions you would like to be answered in the consultationAvailable Date & Time :Your Available Date:Your Available Time: : AMPMHHMMAM/PMTo be confirmed later with Le GabaritSomebody from our clinic will follow up with you to settle paymentSubmitReset Share to Live Well:
