CLUB NUTRICHOIX - PRE-APPOINTMENT NUTRITION QUESTIONNAIRE

GENERAL INFORMATION

Email *

Phone *

Reason for consulting *

Weight loss Reduce abdominal fat / waist circumference Prediabetes / Diabetes High blood pressure High cholesterol PCOS (Polycystic Ovary Syndrome) Uterine fibroids Other __________

Please answer this question.

Please specify your reason for consultation: *

List any known medical conditions (if applicable)

List any medications you are currently taking (if applicable)

List any vitamins, minerals or supplements you are currently taking (if applicable)

Do you have any food allergies or intolerances? *

NoYesNo

Do you have insurance coverage if you choose to be followed by a registered dietitian? *

NoYesNo

Do you have a family doctor? If yes, please provide their name, contact information or the name of their clinic.

NoYesNo

MORE ABOUT YOU

Please tell us a little more about your weight history or the health condition for which you are seeking nutrition support. *

What are your expectations for your nutrition support? *

BODY MEASUREMENTS

Date :

What is your current weight? Please specify lb or kg. *

What is your height? Please specify cm or ft/in *

What is your current waist circumference? Measure around your abdomen at the level of your navel, while relaxed and without pulling your stomach in. Please specify cm or in

What are your weight and waist circumference goals for the next 4 to 6 months? *

EXERCISE HABITS

Do you currently exercise? If yes, please indicate the type(s) of exercise you do and your total exercise time per week. *

NoYesNo

PRE-APPOINTMENT NUTRITION QUESTIONNAIRE

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GENERAL INFORMATION

MORE ABOUT YOU

BODY MEASUREMENTS

EXERCISE HABITS

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