Nutrition Evaluation

Questions marked with an * are required

* What is your age?

* Please list your Height (feet/inches) and Current Body Weight (lbs.)

* Please list your desired or target weight?

* Do you have any food allergies or food intolerances? Please list

* Please list current physical activity and include: Type of activity, how many days per week, how many minutes.

* Please list any medications both prescription and over the counter, and any supplements you currently take.

* Do you have a history of repeat dieting or calorie restriction in attempt to lose weight?

Yes

* Are you Vegan or Vegetarian? If Vegetarian please specify type

Any specific information you feel may be beneficial for the Registered Dietitian to know?

(ie. High stress home life, binge eater, hate cooking, frequently eating out)