Order Number Name: Pronouns: Email Address * Height: Age Body weight: Waist circumference: *Weight and waist measurements should be measured in the AM before eating/drinking and after using the bathroom. *Measure waist circumference around the navel (belly button). Skip this step for now if you do not have a tape measure. 1a. What is/are your short-term goal(s) over the next 12 – 16 weeks that relates to your nutrition? 1b. What is/are your long-term goal(s)? 2. Health history Provide information on your health that could be of importance to your goal (i.e. history of thyroid dysfunction, elevated fasting blood glucose, on medications that affects appetite/bodyweight e.t.c.) 3. Do you know how to count macronutrients or use app such as MyFitPal track? Yes No Note: If, “no”, download a food tracking app such as MyFitnessPal to start tracking your daily food intake 4. Discuss other concerns not addressed in the above questions:
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