Initial Assessment Questionnaire
  • Nourish & Flourish Image

    Initial Assessment Questionnaire

    Getting To Know You (confidential)
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  • How do you prefer me to contact you?*

  • About You

    The more I learn about your lifestyle, your needs, etc. the more I can assist you.
  • What THM or healthy cookbooks do you have?*

  • What do you want to achieve?

  • Click as many as apply.*

  • Right now, how would you rank your overall eating / nutrition habits? 1= Horrible and 10 = Awesome!*

  • Are you currently pregnant or nursing?*
  • Do you have now, or in the past been diagnosed with the following? If so, please specify.*

  • Do you experience any of these symptoms? Click as many as apply:*

  • How Ready, Able & Willing Are You?

    Be honest - no judgement here.
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  • Disclaimer

  • Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation.


    Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.

  • Whew! That was long but you made it!

    I will look over your form and get back to you within 48 hours. I can't wait to start working with you!
  • Susan
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