Assessment Form (Confidential)

  • We take a whole-person approach to your health concerns. We recognize that many health concerns have both a physical and emotional component to them. To get to the root of your concern(s), we will be asking you many questions that will help us to fully assess your concerns and the impact that it is having on your life. If any of these questions don’t apply to you or your concerns, just leave them blank. Thank you for taking the time to share your story with us!
  • Personal Details

  • Health Goals

    What are your main health goals? Why do you wish to meet with a nutritionist?
  • Let's Talk about Your Food & Food Habits

    Here's where you get to share all about the foods you eat.
  • Please share how many times a day you eat, and approximate times you eat.
  • Do you eat meals with family, home alone, on the run, in restaurants, etc? Do you eat sitting at a table, in front of TV or computer, standing, etc?
  • Please share 2-3 examples of your typical breakfast, lunch, dinner and snacks.
  • About Your Digestion

  • Gas? Bloating? Fatigue? Other? Please explain.
  • Do you strain when you have a bowel movement? Do you have loose bowel movements? Please explain.
  • About Your Lifestyle

  • Please indicate – 1 = low, 10 = high. How does your stress manifest? Do you use any coping mechanisms?
  • How often? For how long? What type of exercise?
  • Do you nap? Do you fall asleep easily? Do you stay asleep through the night? Do you awaken feeling rested in the morning?     
  • Do you enjoy your work? How many hours per day do you work?
  • Your Health History

  • Do you take birth control pills? Are you pregnant? Do you suffer from PMS? Are you menopausal? Have you experienced a decline in sexual interest? If yes to any of these questions, please describe:
  • Please use this space to share any additional pertinent information.
  • Please sign your name and include today's date.