NUTRITION COUNSELING

PRE-ASSESSMENT FORM

What do you want to achieve from working with a nutritionist?

What does a healthy diet look like to you?

Describe any changes in the diet.

How many servings of fruit and vegetables do you have per day?

What is your relationship with food?

What medication are you taking?

List any health conditions/chronic illnesses/allergies.

What is your preferred language?

What is your name?

Please provide your email address.