Nutrition Assessment : OverSeas

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: OverSeas

Name

First

Last

Blood Type

Telephone number

Area Code

Telephone number

Phone Number

Weight

Height

Date of birth

Do you have any medical issues ? if yes please provide details

High cholestrol

Hypetension

Diabetes

other

Medications

Goal Weight

Number of Kids (if you are a mother)

Date of Last Delivery (if you are a mother)

Please indicate the breakfast you would have on a typical week day

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?

Work

Home

Errands

OtherOther

Please indicate your lunch on a typical week day

Please indicate the snack after lunch on a typical week day

Do you have dessert every day

Yes

Almost every day

How much water do you drink per day?

Half a liter

1 liter

2 or more liters

How often per week does child consume the following?

What types of food do you not consume and completely dislike?

What is your favorite food?

Who cooks in your home?

How often do you exercise per day?

0-30 minutes

30 minutes-1 hour

1-2 hours

No time at all

None but willing to exercise for 30 minutes 3 times a week

None but capable of exercising 1 hour 3 times a week or more

Have you tried any diets before and have you been to a dietitian?

I have never been to a dietitian

I have been to a dietitian before

I have tried several diets mysef and they did not work

OtherOther

Please mention your main concerns and all questions you would like to be answered in the consultation

Available Date :

Your Available Time:

To be confirmed later with Le Gabarit

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

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Nutrition Assessment : OverSeas

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