Nutrition & Lifestyle Assessment
A dietitian-style intake: eating patterns, goals, and the honest obstacles.
5 questions · 1 page · about 3 minutes to answer · fully editable after you start
The first nutrition consultation goes further when the assessment arrives beforehand. This intake maps current eating patterns, cooking habits, and previous diet attempts, then asks for the goal in the client's own words and the obstacle they already know will be hardest.
The already-know obstacle question does the heavy lifting: clients almost always name the real barrier – time, stress eating, travel, family meals – and the plan that addresses it directly is the one that survives month two.
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Page 1
Your eating patterns
This assessment asks about your eating, activity and daily habits. Your answers give your practitioner a starting point for advice that fits your life. It takes about 3 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.In a typical week, how often do you...*
| Rarely | 1-2 times | 3-5 times | Daily | |
|---|---|---|---|---|
| Cook meals at home | ||||
| Eat takeaway or fast food | ||||
| Skip meals | ||||
| Snack late at night |
Q2.In your own words, what do you want to achieve?*
Q3.Have you tried structured diets before?
- No
- Yes, once or twice
- Yes, many times
Q4.What do you already suspect will be the hardest obstacle for you?*
Q5.How ready are you to make changes right now?
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