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*Indicates required

*Name:
*Email:
*Phone:

Gender:

Date of Birth:

 / /

Height:

ft in

Weight:

lbs

Goal Weight:

lbs

Body Fat:

%

RMR:

Medical History (heart disease, diabetes, cancer, IBS, hypertension, high cholesterol, etc):

Medications & Supplements:

Fitness/Nutrition Goals

1)

2)

3)

Previous Nutrition Programs Followed? Were you successful? Why of why not?

What would you identify as your biggest obstacles to achieving your goals?

How often do you dine out? At what restaurants?

Current physical activity - Frequency, Intensity, Time Spent:

List an example of typical foods that you consume for each meal/snack. Include times and portions whenever possible.

Breakfast:

Morning Snack:

Lunch:

Afternoon Snack:

Dinner:

Evening Snack:

Food Likes/Dislikes

Yes

No

Comments:

Whole Grain Breads

White Breads

Bagels

English Muffins

Tortillas

Pitas

Hot Ceral/Oatmeal

Cold Cereals

Rice

Pasta

Crackers

Popcorn

Granola

Apple

Pear

Banana

Grapefruit

Peach

Nectarine

Plum

Berries

Melon

Pineapple

Kiwi Fruit

Mango

Dried Fruit

Canned Fruit

Juice

Other

Skim Milk

2% Milk

Whole Milk

Yogurt

Cheese

Cottage Cheese

Food Likes/Dislikes

Yes

No

Comments:

Salad/Mixed Greens

Dark Green Leafy Vegetables

Carrots

Tomatoes

Peas

Cauliflower

Broccoli

Green Beans

Corn

Squash

Mixed Vegetables

Potatoes

Sweet Potatoes

Beans

Nuts

Seeds

Peanut Butter

Meat

Pork

Chicken

Turkey

Ham

Lunch Meats

Fish

Tuna

Tofu

Eggs

Egg Substitutes

Vegetable Oil

Olive Oil

Shortening

Margarine

Butter

Mayonnaise

Salad Dressing

Light Salad Dressing

Sour Cream

Cream Cheese

Half and Half Cream

Coffee

Tea

Soda

Diet Soda

Beer

Wine

Alcohol

Energy Bars

Meal Replacement Shakes

Other Food Likes/Dislikes:

Comments:

8870 Rixlew Lane Suite 203 • Manassas, VA 20109 • Phone: 703.396.9444

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