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Nutrition Assessment Form
Our approach requires us to have a thorough understanding of your health history to determine underlying causes affecting your health.Please take your time to complete this form carefully and thoroughly.
Gender
*
Male
Female
Do you drink alcohol?
*
Yes
No
Do you smoke cigarette?
*
Yes
No
Do you use drugs?
*
Yes
No
Are you currently taking any food or nutritional/herbal supplements?
Yes
No
Please indicate whether you or a family member have/had any of the following conditions:
*
Cancer
Cardiovascular Disease
High Blood Pressure
High Cholesterol
Others
Are you currently being treated for any medical conditions?
*
Yes
No
Have you ever been advised by your physician to follow a special diet?
*
Yes
No
Do you exercise?
*
Yes
No
If so, how often?
*
Daily
Few times a week
Rarely
Type of exercise
*
Walking
Aerobics
Yoga
Cycling
Swimming
Others
Do you skip meals?
*
Yes
No
How many days per week do you eat
*
Breakfast
Lunch
Dinner
Do you eat out?
Yes
No
Please specify if you drink any one of these more than once in a week..
*
Decaf coffee
Green Tea
Coldrinks
Others
Do you have good energy levels?
*
Yes
No
Inconsistent
Does napping help?
*
Yes
No
Do you want to change your eating habits?
*
Yes
No
Did you have any expectations from coming to see the nutritionist today?
*
Yes
No
Your Company Name
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Twitter
Linkedin
Google+
A brief intro is always great. It's Helps people to identify your company.
Address
[email protected]
800-555-0101
yoursite.com