Nutrition Questionnaire

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MS, RD, LD

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Nutrition Assessment

First and Last Name

Please tell me what made you reach out to me? Why do you need to make changes now?

I am tired of dietingI have gained my weight back that I lost while dietingI need a better plan to maintain my healthy weight long-term (preventing gradual gain) I want to lose weight without dieting, having to starve myself, and giving up foods I enjoy.Other

Explain

What are the 3 biggest health and nutrition goals you have right now?

I want a healthier relationship with foodUnderstand how to eat to be healthier and prevent weight gainRegulate my blood glucose, blood pressure, or cholesterolHave more energyLose weight and keep it off long-termOther

What barriers or challenges have prevented you from reaching your goals? How will nutrition coaching help address these challenges?

What are your food triggers? Please explain.

What are your food traumas? Please explain.

What are your emotional eating patterns/behaviors? Please explain.

Envision yourself 6 months after receiving nutrition coaching that helped you meet and exceed your nutrition and health goals. Describe how you will feel and what life looks like then.

Increased confidenceOverjoyedAccomplishedAble to fit into my favorite jeans againHaving energy to play with my kids or move easierAble to get off medicationOther

On a scale of 1 to 10, how important is it for you to reach your goals?

Are you willing to be an active participant in the coaching process, by putting in time and effort, when asked to do activities by your coach?

YESNO

Achieving sustainable lifelong healthy habits takes both a financial and time commitment. Are you ready to invest in both right now?

YESNO

Is there another person who needs to be involved in the decision about the financial investment that nutrition coaching requires? If the answer is yes that person needs to be present for the session.

YESNO

If you could work with me for 6 months, how much are you willing to invest?

Submit

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