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.

* Required

Nutrition Assessment: OverSeas

Name *

Name

First

Last

Email *

Blood Type *

Telephone number *

Area Code

Telephone number *

Phone Number

Weight *

Height *

Do you have any Intolerances

Eggs

Dairy

Gluten

Medications

Beans

OtherOther

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

Fruits

Biscuits

Vegetables

Chocolate

I do not have snacks

Tea

OtherOther

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 *

Home made food

Burger outside home

Sandwiches outside home

Salad outside home

I skip lunch

Fries

Soda

Juice

OtherOther

Please indicate the snack after lunch on a typical week day

Fruits

Biscuits

Vegetables

Chocolate

I do not have snacks

Tea

OtherOther

Please indicate your dinner on a typical week day *

Take out

Home made sandwich

Same food from lunch

I eat out most days

I do not have dinner

Soda

Fries

Juice

Sandwiches

Pasta

Pizza

OtherOther

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?

Fish *

1/week

2/week

3/week

4/week

Every day

Chicken *

1/week

2/week

3/week

4/week

Every day

Meat *

1/week

2/week

3/week

4/week

Every day

Fruits *

1/week

2/week

3/week

4/week

Every day

Nuts *

1/week

2/week

3/week

4/week

Every day

Chocolate/Dessert *

1/week

2/week

3/week

4/week

Every day

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

What is your favorite food?

Who cooks in your home?

Myself

Spouse

Family Member

Chef or Helper

No cooking, mainly take out

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

What is the reason you feel you are not losing weight? Or gaining weight (depending on your goal)

I have many unhealthy snacks

I eat large portions and don't stop when I feel full

My food choices are often not healthy

I have no schedule and my day is messy

I eat well but I am not seeing results

I love food too much

No time to cook

I eat when I am bored

I eat when I am stressed

I eat at night

When I see food I eat it

OtherOther

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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