Nutrition and Meal Plan Assessment Questionnaire - Ask The Nutritionist

First Name

Last Name

Your Email

Phone Number

Occupation

Date of Birth

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On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:

Significantly change your diet: 12345

Take nutritional supplements each day: 12345

Engage in regular exercise: 12345

Keep record of everything you eat per day: 12345

Modify your lifestyle for your health 12345

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From a scale of 1 to 5, select the intensity of each type of activity you do below.

Stretching/Yoga: 12345

Aerobics: 12345

Weight lifting, pilates: 12345

Sports 12345

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Current Weight

Current Height

Weight a year ago

Have you had any recent changes in your weight that concern you? YesNo

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Comments or Additional Information

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