Assessment Form

Assessment Form
Date *

Month Day Year
Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
E-mail *
Gender *

Male Female
Age?
Weight (lbs)measured as of this morning *
Height (inches) *
Goal weight (lbs)
How many times per week do you exercise?
For how long?

30 - 45 minutes 1.5 hours 1 hour 2 hours or more
what exercises/activities do you engage in?

Walking Cardio machines Jogging Strength training Play Sport
LIFESTYLE INFORMATION
What do you do for a living?
What is the activity level at your job?

None Moderate High
Does your job entail shift work?

Yes No
If you follow a more regular schedule, when do you work?

Days Afternoons Nights
How often do you travel?

Rarely Few times per week Few times per month Weekly
If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at leas 3x per week)?

Yes No
If yes how long ago was it, and how long did it last?
If you have any diagnosed health problems, list the condition(s)
Do you have blood relatives who have had or has any of the following conditions
Do you have any of the following conditions?
Are you taking medication? *
If yes please list medications
What additional therapies or interventions are being taken for the given health problem(s)?
If you have/had any injuries please list them
What additional therapies or interventions are being taken for the given injury(s)?
Do you smoke Tobacco?
If yes how often?
DIET HISTORY
Do you drink alcohol?
If yes how often?
List any food alergies that you have
List foods you like
List foods you dislike
List foods you would eat for one day at breakfast, lunch, dinner, supper and snacks (indicate the time you would eat each meal)
Are you on or have ever been on any special diet?
If yes please state
How often do you grocery shop?
How much money do you spend on groceries per month?
How many meals do you eat per day?
How many meals do you eat in restaurants or fast food places per week?
If you are currently using any nutritional supplements, please list them below, including doses
What change/s would you like to make? *
Please indicate some topics or areas you would want me to focus on.
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