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Lifestyle and Nutritional Attitude Assessment |
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| What do you think are your nutritional needs ? | |
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| What do you see as your major issues with food, weight management and lifestyle choices ? | |
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| What do you see as your own barriers to dealing with food and lifestyle issues ? | |
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| What are your personal goals for weight loss, improvement of medical conditions, and improvement of your overall health and wellness ? | |
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| Do you have any specific medical/health conditions (insulin resistance, diabetes, hypertension, high cholesterol, PMS, menopause, arthritis, fibromyalgia, chronic fatigue syndrome, elevated cholesterol, PCOS, gestational diabetes, food allergies, high BMI, Obesity, etc) | |
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| Do you exercise regularly ? What do you do, and how often do you do it.? | |
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| What do you see as major barriers to exercising regularly ? | |
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| How do you feel when you first wake up in the morning...mid morning....noon....afternoon.....after work....dinner.....at bedtime. | |
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| How does your energy level change throughout the day ? | |
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| What are your favorite foods and snack foods ? | |
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| What types of foods do you not like to eat ? | |
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| Are there any foods to which you think you have an allergy, or to which you have noticed a physical response you did not like ? | |
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| Other comments you would like to make that have significance to you. | |
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| Name | Date |
| Address: | |
| Email: | Phone (if desired) |