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 First Last Last Email * Blood Type * Select Blood TypeO+O-A+A-B+B-AB+AB- Telephone number * Area Code Telephone number * Phone Number Weight * Height * Do you have any Intolerances No 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) Select a value0123455+ 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 No 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 * 0 1/week 2/week 3/week 4/week Every day Chicken * 0 1/week 2/week 3/week 4/week Every day Meat * 0 1/week 2/week 3/week 4/week Every day Fruits * 0 1/week 2/week 3/week 4/week Every day Nuts * 0 1/week 2/week 3/week 4/week Every day Chocolate/Dessert * 0 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: 121234567891011 : 0030 AMPM To be confirmed later with Le Gabarit Somebody from our clinic will follow up with you to settle payment reCAPTCHA If you are human, leave this field blank. Submit