• Name
  First Last
• Email
• Date of Birth
  MM / DD / YYYY
• Age
• Height
• Current Weight
• Ideal Weight
• Weight History
  Start with high school and list possible reasons for weight fluctuations
• Exercise
  What are you currently doing for exercise?
• Sleep
  How many hours do you sleep? Quality?
• Allergies or Food Intolerances
• Stress
  Rank on 0-10 scale and list major causes
• Supplements
  What vitamins, minerals, and protein powders, etc. do you take? List frequency and reason for use.
• Medical History
  Have you ever had abnormal lab results? Any chronic conditions?
• Family Medical History
  Heart disease, cancer, stroke, diabetes, thyroid disorders, osteoperosis
• Medications
• Disordered Eating
  Do you have a history of any abnormal eating behaviors? Under eating? Over eating?
• Motivators & Goals
• What is motivating you to seek nutrition counseling?
• What are your short-term goals?
  Within the next 16 weeks
• What are your long-term goals?
• What are your obstacles to living a healthier lifestyle?
• Food & Beverage Intake
• Who prepares meals in your home? For How many?
• Who does the shopping? Where?
• How many of your meals per week are home prepared?
• How many days per week do you eat out?
• Restaurants you most often frequent
• Drinks
  Please list approximate quantity per day or per week
• Food
  Please include as many details as possible: approximate times, quantities, brands, etc. It may be relevant to include a work day and a non-work day and/or a healthier day and a less healthy day.
• Food preferences
  Are there any foods you hate? Is it due to flavor, texture, temperature, color, fear, etc.? Think through different food categories: fruits, vegetables, meat, fish, beans, starches, nuts, seeds, dairy, etc.
• Biggest food challenges and areas for improvement