Free Nutrition Assessment

 

If you'd like a free analysis of your current eating habits and health goals by a Registered Dietitian, you have found your website!  Simply click on services@apexnutritionllc.com , copy the following form straight into the text of the email, complete it, and send it.  

Or, you can copy it onto a word processing document and mail it to:

Apex Nutrition, LLC, PO Box 2074, Crested Butte, CO 81224.   

 

Kelli Jennings, RD will respond by email* and provide feedback and direction regarding your eating habits.  She will give you the jumpstart you need to change your lifestyle, if needed! There is absolutely no obligation, just an opportunity to get on, or stay on track!

ALL INFORMATION WILL BE KEPT COMPLETELY CONFIDENTIAL!

 

___________________________________________________________________________ 

 

FREE INITIAL NUTRITION ASSESSMENT

 

First name:___________  Age: ____   Date:_____________ Email Address:__________________________

   Phone number (if you'd rather be contacted by phone):____________________________________

 

How did you find this site?  ___yahoo search        ____google search         ____other:____________________

 

1. What are your nutrition/health goals?

 

 

           Optional: If you are already interested in a specific service from Apex Nutrition, which one is it?

 

 

2.  What is your motivation for change (who or what)?

 

 

3. How willing are you to look at nutrition changes as a “way of life” and not just a diet?

 

 

4. Height:

 

5.Weight:

Has this weight changed in the last year? If so, what was your usual weight:

Desired Body Weight:

 

6. Think about what you ate yesterday.  You woke up, did you eat…
            Breakfast?

If so, what was it? (Be sure to include drinks)

 

 

Snack?

If so, what was it?

 

 

Lunch?

If so, what was it?

 

Snack?

If so, what was it?

 

 

Dinner?

If so, what was it?

 

 

Dessert?

If so, what was it?

 

7. Would you say this represents your usual eating habits?

If not, what is usually different?

 

 

 

8.  How often do you eat out at restaurants?  Which ones are most common?

 

 

 

9.  During the day, when you are not “exercising,” how would you describe your lifestyle (please indicate on line)?

For example, circle sedentary if you sit at a desk during most of the day,

Or active – very active if you are a construction worker and constantly carrying things, climbing things…

 

            ___Sedentary        ___Slightly Active      ___Active     ____Very Active

                    

 

10. What is your exercise schedule like?

 

 

 

 

 

 

11. Are you currently training for any type of sporting event?

 

 

 

12.  What strategies do you currently use (if any) to fuel your exercise/training?  For example, do you try to eat a recovery meal, drink a carbohydrate/electrolyte sports drink during exercise, etc?

 

 

 

13.  How would you describe your energy levels throughout the day?

 

_____Usually tired   ___Highs & lows   ___Consistent, moderate energy  ___High energy

 

 Other__________________________

 

 

14. Do you have any special nutrition concerns you want Kelli to know about?

 

 

 

 

 

15.  Please place an "x" on the following lines to indicate Medical History

                                     Personal History                         Family History 

 

Heart Disease                     _____                                         _____

High Cholesterol                 _____                                         _____

High Blood Pressure      _____                               _____

Diabetes                       _____                               _____

Colon Polyps                 _____                               _____

Colon Cancer                 _____                               _____

 

 

16. Any Known Allegies or Food Sensitivities?

 

 

17. Any activity restrictions?

 

 

18. Do you regularly take any medications (Zocor, aspirin, etc) and/or supplements (ex: multivitamin, calcium, etc.)?