Nutrition Client Assessment Form Template [49 questions] | Practice

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Nutrition Client Assessment Form Template

As a nutrition professional, you know the importance of getting to know your clients and their individual needs. With the Nutrition Client Assessment Form Template, you can easily obtain a better understanding of your clients' current nutrition habits and health goals.

This comprehensive form will help you collect essential information from each client, such as their medical history, lifestyle habits, nutrition goals, and food preferences. With this information, you can get a clear sense of where you clients are, what they're struggling with, so you have a good baseline before you provide any advice on what to do.

In addition, the Nutrition Client Assessment Form Template keeps track of important details, such as allergies, dietary restrictions, and other health-related conditions. This information will help you to create a plan and provide advice that are tailored to each client’s health needs.

The form is easy to fill out and understand, which makes it simple for your clients to provide you with the information you need. With this form, you can work with your clients to create a nutrition plan that is tailored to their individual needs and goals.

Nutrition Client Assessment Form Template

Date of Birth:
Height:
Current Weight:
Current Body Fat % (if known):
How do you prefer me to contact you?
If you had to identify your biggest WIN over the last month, what would it be and why?
What have you discovered you excel at doing in the last month?
In the last month, what behavioral change(s) has contributed most to your success in achieving your goals? Why?
Which things haven't work well for you in the last month and why not?
In the last month, what behavior(s) have most inhibited your success in achieving your goals? Why?
Given where you are right now, how, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Right now, what are your goals? Check all that apply.
Have any of your goals changed in the last month? If so, how and why?
Considering the last month, how would you rank your overall eating / nutrition habits? (1 = Horrible; 5 = Awesome)
Why did you rank your eating / nutrition habits as such?
In the last month, where have you struggled with your nutrition?
On a scale of 1 to 5 how would you rank your health right now? (1 = worst; 5 = awesome!)
Why did you rank your health as such above?
Are you doing any new forms of sports and/or exercise in the last month?
In the last month, approximately how many hours a week have you done other types of physical activity? (e.g. housework, walking to work or school, home repairs, moving around at work, gardening)
How many time a week do you do cardio workouts?
How many times a week do you strength train or lift weights?
What supplements do you currently take?
Right now, what are your daily macros goals?
Right now, what is your daily calorie goal?
In the last month, who did most of the cooking in your household? Check all that apply.
In the last month, how did you eat on the weekend/your days off of work? (e.g., do you dine out, drink alcohol, eat things you normally don't during the week, eat more quantity of food, eat at friends/family's homes, eat fast food)
In the last month, how meals did you eat out in an average week?
In the last month, how many alcoholic beverages did you drink in an average week? Check all that apply.
Have you been diagnosed within the last month with any significant medical condition(s) and / or injuries?
Right now, are you taking any medications, either over-the-counter or prescription, that I should know about?
On a scale of 1-5, how do you feel about your schedule, time use, and overall busy-ness? (1 = My life is packed and insane.; 5 = My life is perfectly calm and relaxed.)
Given all the demands of your life, what is your typical stress level on an average day? (1 = no stress; 5 = extreme stress)
In the last month, on average, how many hours per night do you sleep?
Has your job or activity level changed significantly in the last month?
If your job or activity level changed significantly in the last month, please explain how so?
Look through your food journal. Based on what you recorded, how many days in the last month did you record all of your meals?
(1 = 0-10% ; 2 = 10-35%; 3 = 35-65%; 4 = 65-95%; 5 = 95+% of the days)
In the last month, how have you eaten on the weekend/your days off of work? How compliant have you been on the weekends with hitting your macros?
(1 = I very rarely hit my macros; 5 = I always hit my macros 95+%)
On a scale of 1 to 5 how would you rank your energy level? (1 = Worst, I'm dead.; 5 = Awesome, nothing can hold me back.)
On a scale of 1 to 10 how would you rank your average daily hunger? ( 1 = absolutely starving; 5 = stuffed to the gills)
How do you normally cope with stress? Are you coping with stress in different ways since you started this process/in the last month?
Overall, in the last month, how compliant have you been with the plan we've agreed to? (1 = I ignored it.; 5 = I executed it very well.)
Have your expectations for yourself changed in the last month?
Have your expectations for me as your coach changed in the last month? If so, please explain.
Do you need more external accountability from me? Explain.
How long do you think it should take you to reach your goal?
How confident are you in your ability to accomplish your nutrition / fitness goals? (1 = It's impossible.; 5 = I have ZERO doubts.)
What are you prepared to do to work towards your goal(s) in the coming month?
How will you know when you have reached your goal? Be very specific.

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