Name
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First Name
Last Name
Email
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Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Gender/pronouns
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Emergency contact
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Height
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Weight
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How would you rate your current state of health?
What are your main health goals?
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ie. improve energy, balance hormones, support gut health and digestion, make healthier diet choices, etc
What specific concerns or symptoms are you currently experiencing? Please be specific and include date of onset.
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What do you hope to achieve from our work together? What expectations do you have of me as your nutritionist?
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Please list any diagnosed medical conditions:
Current medications (including over-the-counter):
include dosages & frequency
Past medications:
How many times have you been treated with antibiotics?
Current supplements, vitamins, minerals or herbal products:
include brands, dosages & frequency
Please list all major hospitalizations, surgeries, injuries, diseases, traumatic events and the year of onset:
Family health history:
any relevant conditions such as diabetes, thyroid issues, cancer, heart disease, autoimmune, etc
Occupation & typical work schedule:
Physical activity:
type, frequency, duration
Stress levels:
What are the major sources of stress in your life?
ie. financial, job, family, etc
Coping mechanisms for stress:
ie. meditation, exercise, alcohol, food, none, etc
What behaviours or lifestyle habits do you currently engage in regularly that you believe support your health?
What behaviours or lifestyle habits do you currently engage in regularly that you believe are detrimental to your health?
What potential obstacles do you anticipate in addressing the lifestyle factors that are undermining your health?
Sleep habits (check all that apply):
Energy levels throughout the day (morning, afternoon, evening):
Do you drink alcohol? If yes, how often & how much?
Do you smoke or use recreational drugs?
How many bowel movements do you typically have per day?
Stool consistency:
ie. loose, soft, formed, hard, pellets, alternating, etc
Do you experience any of the following (past or present)? Check all that apply.
Food allergies, intolerances or sensitivities:
Do you currently have a menstrual cycle?
Period length (days):
PMS symptoms:
ie. cramps, breast tenderness, mood changes, acne, etc
Are you currently pregnant, trying to conceive or postpartum?
Current form of birth control (if any):
Food preferences:
ie. keto, carnivore, animal-based, vegan, vegetarian, paleo, gluten-free, dairy-free, etc
Foods you love:
Foods you dislike:
What does a typical day of eating look like (please be as detailed as possible)?
include breakfast, lunch, dinner, snacks and beverages
Do you experience emotional or stress-related eating?
Have you worked with a nutritionist, dietitian or health coach before? (If yes, what was helpful/not helpful?)
Anything else you think I should know about your health, lifestyle or nutrition habits?
How did you hear about me?
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I understand that nutrition consultations are not a substitute for medical advice. I agree to consult my healthcare provider before making any major dietary or lifestyle changes.
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