Client Assessment

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Client Assessment

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Just 30 seconds to a healthier tomorrow.

1Personal & Health

2Diet & Lifestyle

1Client Details

Full Name *

Phone *

Email *

Address *

Birthdate *

Date

S M T W T F S

Age *

Sex *

Height (ft) *

Height (in)

Weight (kg) *

2Health History

Medical concerns (e.g. Pregnancy) *

Do you have complaints about any of the following? *

Cancer High blood pressure Diabetes Osteoporosis Heart disease Thyroid disorder High cholesterol PCOD Appetite issues Constipation Bloating/gas Diarrhea Dry skin Eczema Chewing or swallowing Indigestion Mental difficulties Sudden weight changes Sleeping in light Stress None of the above

Tobacco/Smoking *

How much?

Occasional Regular

Do you enjoy physical activity? *

What kind of activity?

Food allergies or intolerances *

3Drug History

List any prescribed, OTC, herbal, or vitamin supplements *

4Diet History

Have you ever followed a special diet? *

Do you drink alcohol? *

Foods you do not eat *

Meal Preference *

Vegan (No Animal Products) Vegetarian Vegetarian (But Eat Eggs) Vegetarian (Jain) Non-Vegetarian

Dietary Recall — What do you typically eat?*

MealFood Consumed

Breakfast

Lunch

Snacks

Dinner

Mid-Night Snacks

What changes would you like to make? *

Improve my eating habits Improve my activity level Learn to manage my weight Improve cholesterol/triglyceride levels Other

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Full Name*

Country*

Phone*

Health Goals and Concerns

Neha sahaya - Eat for the body u want, not for the body u have

Typically replies within minutes

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