Order Number Name: 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. Body weight history. Provide estimates of the following… a. Body weight 1 month (4 weeks) ago: c. Body weight 6 months ago: b. Body weight 3 months ago: d. Body weight 1 year ago: e. Provide information on significant body weight changes beyond 1 year ago: 3. 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.) 4. 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 MyFitPal to start tracking your daily food intake. Skip question 5a for now but try your best to answer question 5b and 5c. 5a. List your current carbohydrates, proteins, and fats macronutrients. If it varies from day to day, provide information for several days. 5b. Give me an example of your meal plan/choices. 5c. Describe your diet or eating habits over the past few months. 6. Dietary Preference/lifestyle. i.e. vegetarian, vegan, or a mixed diet which is a diet consisting of all food type, intermittent fasting e.t.c. 7. List any food allergies: 8a. How much cardio are you currently doing? Provide number of days per week and duration per session. 8b. Describe your cardio regimen in the past few months. 9. What supplements have you taken in the last 6 months? Are there any other supplements you would like to take that relates to your goal? 10. Discuss other concerns not addressed in the above questions:
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