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.

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Nutrition Assessment : Online
Name
Name
First
Last
Area Code
Phone Number
Do you have any Intolerances
Do you have any medical issues ? if yes please provide details
Please indicate the snack after breakfast you have on a typical week day
What do you do between breakfast and lunch on a typical day?
Please indicate your lunch on a typical week day
Please indicate the snack after lunch on a typical week day
Please indicate your dinner on a typical week day
Do you have dessert every day
How much water do you drink per day?

How often per week does child consume the following?

Fish
Chicken
Meat
Fruits
Nuts
Chocolate/Dessert
Who cooks in your home?
How often do you exercise per day?
What is the reason you feel you are not losing weight? Or gaining weight (depending on your goal)
Have you tried any diets before and have you been to a dietitian?
Your Available Time:

To be confirmed later with Le Gabarit

Somebody from our clinic will follow up with you to settle payment

DO NOT EAT LESS, JUST EAT RIGHT.

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