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Home
About Me
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Resources
Nutrition Assesment Form
In the Media
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Nutrition Blog
Hot Topics
Media Appearances
Nutrition Store
Shop Now
My Account
Contact Me
Nutrition and Meal Plan Assessment Questionnaire - Ask The Nutritionist
Home
Meal Plan Assessment
1
.
General Information
2
.
Goals Assessment
3
.
Physical Activity
4
.
Weight
5
.
Additional Information
First Name
Last Name
Your Email
Phone Number
Occupation
Date of Birth
Continue
On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:
Significantly change your diet:
1
2
3
4
5
Take nutritional supplements each day:
1
2
3
4
5
Engage in regular exercise:
1
2
3
4
5
Keep record of everything you eat per day:
1
2
3
4
5
Modify your lifestyle for your health
1
2
3
4
5
Continue
From a scale of 1 to 5, select the intensity of each type of activity you do below.
Stretching/Yoga:
1
2
3
4
5
Aerobics:
1
2
3
4
5
Weight lifting, pilates:
1
2
3
4
5
Sports
1
2
3
4
5
Continue
Current Weight
Current Height
Weight a year ago
Have you had any recent changes in your weight that concern you?
Yes
No
Continue
Comments or Additional Information
Previous
Continue
Submit Assessment
