New Clients

New clients of Summer Lamons Nutrition Consulting are requested to fill out the following form.

    Contact Information

    Name (required)

    Address

    Phone number

    E-mail (required)

    Physical

    Age:

    Gender:

    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):

    Time Food
    WAKE
    Breakfast
    Snack
    Lunch
    Snack
    Dinner
    Snack
    SLEEP

    Lifestyle

    Please list current physical activity:

    Do you smoke?
    If so, please list number of packs per day.

    Do you drink alcohol?
    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?

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