NUTRITION ASSESSMENT

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NUTRITION ASSESSMENT & QUESTIONNAIRE

About you…

Name*
Address*
MM slash DD slash YYYY
Please enter a number greater than or equal to 0.

About your goals…

In general, what are your goals?*
check all that apply
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Top 3*
Out of all the changes you’d like to make, which ones feel most important/urgent?
#1
#2
#3
 
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what?
Which of those things worked well for you, and why?
Which of those things didn’t work well for you, and why not?
If you were to consider maybe making more changes to your habits, your health, your eating, and/or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?

About your routines…

Ranking*
Right now, how would you rank your overall eating/nutrition habits?
Physical Activity*
Are you regularly active in sports and/or exercise?
Amount of Physical Activity*
If so, approximately how many hours per week?
What types of sports and/or exercise to you typically do?
What other types of movement and/or activities do you do?

About your environment…

Who lives with you?*
check all that apply
If yes, how many and what are their ages?
Who does most of the grocery shopping in your household?*
check all that apply
Who does most of the cooking in your household?*
check all that apply
Who decides on most of the menus/meal types in your household?*
check all that apply
Support*
Right now, how much do the people and things around you support health, fitness, and/or behavior change?

About your health…

Medical Conditions and/or Injuries*
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
Current Concerns*
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?
Medications*
Right now, are you taking any medications, either over-the-counter or prescription?
Health Ranking*
Right now, how would you rank your overall health?

About your time…

Time*
In an average week, how many hours do you spend on each of the following?
Paid Employment
School or School Work
Traveling and/or Commuting
Taking Care of Others (e.g. children, family)
Unpaid Work (e.g. housework, errands)
Volunteering
 
Adding up all these things, how many total hours per week do you spend doing all these activities?
Please enter a number greater than or equal to 0.
Time Ranking*
Right now, how do you feel about your schedule, time use, and overall busy-ness?

About your stress and recovery…

Stress Ranking*
Considering all the activities you’re involved in (e.g. work, school, caregiving, travel), what is your typical stress level on an average day?
Sleep*
On average, how many hours per night do you sleep?
Do you have trouble falling asleep? Staying asleep? Other sleep challenges? Please elaborate as much as possible
How do you normally cope with your stress?

About your readiness…

READY*
Right now, how READY are you to change your behaviors and habits?
WILLING*
Right now, how WILLING are you to change your behaviors and habits?
ABLE*
Right now, how ABLE are you to change your behaviors and habits?
This field is for validation purposes and should be left unchanged.