Nutrition Intake Survey "*" indicates required fields Email* First Name* Last Name* Age* Occupation* DIETARY HABITSWhat is the average number of meals eaten each day?* Do you skip meals frequently?* Yes No If yes, which meals? (Please check all that apply)* Breakfast Lunch Dinner N/A How much time out of your day do you spend thinking about food?* Less than 10% 10-25% 25-50% More than 50% Please tell us about how your eating habits change weekday vs. weekend. (If no change please put N/A)*When you feel overwhelmed or life gets busy, do your eating habits change?* Yes No If yes, please describe.Please choose how you view your overall health.* Excellent Good Fair Poor Please how you currently feel about your body.* Very Satisfied Satisfied Slightly Dissatisfied Dissatisfied Very Dissatisfied Describe your typical daily meals and snacks.*How many meals and snacks do you usually have in a day?*What are your food preferences and/or dislikes?*Are there any specific foods you crave often?*How often do you eat out or order takeout in a week and what kind of meals do you often order?*LIFESTYLE AND ACTIVITYDescribe your current level of physical activity.*Is there anything else you would like me to know about you or your preferences to ensure our private yoga sessions are tailored to your needs and preferences?*How many days per week do you engage in exercise, and for how long?*Do you have any fitness goals or specific activities you enjoy?*MENTAL HEALTHHave you experienced any recent changes in your life that have contributed to weight loss or weight gain?*How do you manage stress in your life?*GOALS AND EXPECTATIONSWhat are your primary nutrition and health goals?*Are there any specific challenges or obstacles you face in achieving your goals?*What do you hope to achieve through nutrition counseling?*ADDITIONAL INFORMATIONPlease share any other information you would like your certified nutritionist to know.I understand that the advice provided by the nutritionist is not a substitute for medical advice, diagnosis, or treatment. I agree to provide accurate information to the best of my ability. I consent to the nutritionist using this information to develop a personalized nutrition plan.* I understand that the advice provided by the nutritionist is not a substitute for medical advice, diagnosis, or treatment. I agree to provide accurate information to the best of my ability. I consent to the nutritionist using this information to develop a personalized nutrition plan.
