Please take a couple of minutes to complete the following detailed assessment form so we may better serve you. All the information will be kept confidential and will be used only for the purpose of creating a personalized and suitable menu plan for you, our client.


Name
:
Age
:

DOB
:

Sex
:
Male Female
Height
:
Current Weight (kilograms)
:
Occupation
:
Current Exercise Regime : a. Resistance Training (Weight lifting)
  • Number of times per week
:

  • Duration : Here you can put the options starting at
:

Current Exercise Regime : b. Cardiovascular Training (Treadmill, Bike, Crosstrainer)
  • Number of times per week
:

  • Duration : Here you can put the options starting at
:

(Please list any problems below you had in the past or any surgeries, for example, hip replacement, cardiac bypass, knee scope, cancer)

  • Past Medical History

:

Please check all the conditions that apply and use the space below to add any other medical conditions you are currently having

  • Current Medical Conditions

:


Have you ever been on a diet plan that was MEDICALLY ADVISED?

:

Yes No
If yes, please explain briefly below what kind of diet plan that was.

 
Current Eating Pattern

  • How many times per day do you eat?

:


  • Please indicate which meals/snacks you have almost every day:

:

Please complete the following contact information. The nutritionist will be contacting you shortly for more specific information regarding your current eating pattern.

  • Mailing Address

:


  • E-mail address

:


  • Day Time phone

:


  • Evening Time phone

:


  • Mobile phone

:


  • Fax

:

Other details which would help us to assess you better

 


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