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

Name*
Email address *
Blood Type
Telephone number*
-
Weight*
Height *
Do you have any Intolerances
Date of birth *
 / 
 / 
Do you have any medical issues ? if yes please provide details
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?
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?

   0

1/week

2/week

3/week

4/week

Every
day

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

Available Date & Time :

Your 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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