Nutrition Initial Assessment

First name

Last name

Date and time

Month

Day

Year

Time

HoursMinutes

Birthday

Month

Day

Year

Gender

Email

Phone

How do you prefer me to contact you?

Email

Phone Call

Text

Address

What do you want?

Please list all of your concerns about your health, eating habits, fitness, and/or body.

Out of the above concerns, which ones feel most important/urgent and why?

What do you expect?

What do you expect from me as your coach?

What are you prepared to do to work towards your goals?

What do you want to change?

Have you tried anything in the past to change your habits, your health, your eating, and/or your body?

Which of those things worked well for you?

Which of those things didn't work well for you?

How, specifically, would you like your habits, your health, your eating, and/or your body to be different?

Have you already made changes to your habits, your health, your eating, and/or your body recently?

Until now, what has blocked you or held you back from changing these things?

Right now, how would you rank your overall eating/nutrition habits from 1 (Horrible) to 10 (Awesome!)?

Approximately how many hours a week do you do other types of physical activity (e.g. housework, walking to work/school/neighborhood, home repairs, moving around at work, gardening)?

What's around you?

Who does most of the grocery shopping in your household? Check all that apply.

Who does most of the cooking in your household? Check all that apply.

Right now, how much do the people and things around you support health, fitness, and/or behavior change from 1 (Not at all) to 10 (Completely)?

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

Right now, do you have any specific health concerns, such as illness, pain, and/or injuries?

Right now, are you taking any medications, either over-the-counter or prescription?

On a scale of 1 (worst) to 10 (Awesome!), how would you rank your health right now?

Time and stress management

In an average week, how many hours do you spend in paid employment/school/volunteering?

In an average week, how many hours do you spend doing other unpaid work (e.g. housework, errands, taking care of others)?

In an average week, how many hours do you spend traveling and/or commuting?

On a scale of 1 (My life is panicked and insane) to 10 (My life is perfectly calm and relaxed), how do you feel about your schedule, time use, and overall busy-ness?

Given all the demands of your life, what is your typical stress level on an average day on a scale of 1 (No stress) to 10 (Extreme stress)?

How do you normally cope with your stress?

How ready, willing, and able are you to change?

How READY are you to change your behaviors and habits from 1 (Not at all) to 10 (Completely)?

How WILLING are you to change your behaviors and habits from 1 (Not at all) to 10 (Completely)?

How ABLE are you to change your behaviors and habits from 1 (Not at all) to 10 (Completely)?

Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and/or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

Please check this box if you agree to the above statement.

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