New Clients

Contact Information

Name (required)

Address

Phone number

E-mail (required)

Physical

Age:

Gender: MaleFemale

Height: ft in

Current Weight: lbs.

Goals

Goal Weight: lbs.

Health and Wellness Goals

Medical

Please list all current medical condition(s):

Please list any past medical history:

Please list any family medical history:

Please list all medications you take (prescribed and over the counter):

Please list any supplements, vitamins, herbs you take:

Nutrition

Please list any previous nutrition plans, supplements, or diets you have tried in the past:

Please list any known food allergies or intolerances:

How many servings of vegetables do you eat per day?

List your 3 favorite vegetables:

How many servings of fruit do you eat per day?

List your 3 favorite fruits:

Current Nutrition Intake (include time of day, amounts of foods, and ALL beverage
intake):

Lifestyle

Please list current physical activity:

Do you smoke? YesNo

If so, please list number of packs per day.

Do you drink alcohol? YesNo

If so, please list number of drinks per week.

How many times per week do you dine out?

How many times per week do you eat fast food?