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Initial Nutrition Assessment

Please fill out the form below and then Submit to SHAPE before proceeding to the COMPREHENSIVE HEALTH & NUTRITION SURVEY form ... = Required Name: Date: (mm/dd/yy) Your Personal Email Address: 1. Please list your top 3 health & wellness goals: If one of your goals is weight loss what was your heaviest and lowest weight? 2. Please outline significant medical/ diet history: 3. Please list your current exercise routine: 4. What is your weight? 5. What is your height? 6. Have you tried weight-loss diets in the past? Yes No If Yes, what were they and did they work? FOOD FREQUENCY QUESTIONNAIRE - QUANTITY & SPECIFICS Please enter your dietary intake for a typical week, being as specific as possible: For example, if you eat a chicken breast four times per week then the QUANTITY would equal = 4x and the SPECIFICS could say “2 x 6 ounces BBQ and 2 x 6 ounces baked”. Breads Pastas Rice Cereal Fruit Juice Vegetables Beef Chicken Pork Fish/Seafood Spiced Meat Beans Nuts/Nut Butter Eggs Milk Cheese Yogurt Oils Butter Salt Coffee Tea Soft Drinks Alcohol Water Desserts Fast Foods Junk Food/Snacks

 

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