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Initial Nutrition Assessment

Nutrition: Initial Assessment

Step one of our nutrition assessment process. This will collect basic information and help us decide the next step.

Step 1 of 4

25%

Name

First Last

Date of Birth

Gender

Height

Weight

Email

Phone

Preferred method of contact

What are your general goals?

Please list all of your concerns about your health, eating habits, fitness, and/or body.

Out of the above concerns, which ones do you feel are the most important/ urgent?

Have you tried anything in the past to change your habits, health, eating, and/or body? If so, what?

Which of those things worked well for you?

Which of those things didn't work well for you?

Have you already made changes to your habits, your health, your eating or your body recently?

If you were to consider making further changes to your habits, your health, your eating, or your body, what might those be?

Until now, what has blocked you or held you back from changing those things?

How many meals do you eat a day?

1-8 meals per day. How many on average do you eat?

Preferred Eating

What is your preferred eating style?

Meal Plan Serving Sizes (Family sizes)

Breakfast

Lunch

Dinner

Do you want meal plans to reflect individual serving sizes or family sizes? Check the meals you would like meal plans to reflect family sizing.

Do you use Isagenix products?

Yes

No

Our Isagenix users will use shakes as part of their daily nutrition. We can reflect this in the meal guides.

Right now, how would you rank your overall/nutrition habits?

On a scale of 1-10, how would you rank, with 1 being horrible and 10 being awesome.

What is your weekly exercise level?

Very light to Very Intense. If you are training less than 3-4 hours per week, you are in the light category. If you are running 3-5 times per week with no workouts, you are in the moderate. 4-6 hours per week of structured training will be intense. 7+ hours per week will be very intense.

How many hours a week do you engage in other physical activity?

This is housework, school, work, home repairs, gardening, etc.

Who does most of the shopping in your household?

Who does most of the cooking in your household?

Who decides on menu or meal types in your household?

Right now, how much do the people and things around you support health, fitness, and/or behavior change?

On a scale of 1-10, with 1 being not at all and 10 being completely.

Given all the demands of your life, what is the typical stress level on an average day?

On a scale of 1-10 with 1 being no stress and 10 being extreme stress.

On average, how many hours per night do you sleep?

4 or less hours

5 hours

6 hours

7 hours

8 hours

9 hours

10+ hours

How do you normally cope with your stress?

How ready are you to change behavior and habits?

On a scale of 1-10 with 1 being not at all and 10 being completely.

How willing are you to change behavior and habits?

On a scale of 1-10 with 1 being not at all and 10 being completely.

How able are you to change behavior and habits?

On a scale of 1-10 with 1 being not at all and 10 being completely.

Untitled

First Choice

Second Choice

Third Choice

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Initial Nutrition Assessment

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