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95602 02564

Nutritional Assessment

Warm welcome,
This short check-in is about your everyday eating patterns– the way you eat across a regular day and week.

Don’t overthink your answers; go with what feels most true. There is no “perfect diet” you’re competing with here.

This is a private reflection for you, to see your real starting point in improving your dietary habits.
Let us Begin
Basic Details
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Name
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Age (in yrs)
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Gender
Body profile & Health background
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Height
You can write in cm or in feet/inches
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Weight
You can write in kg or in pounds
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BMI
Body Mass Index (kg/m2)
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In the last 6 months, your weight has…
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Have you been told, you have any of the following ?
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Menstrual History
Which of these best describes your current phase ?
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Any menstrual/ hormonal concerns you’d like to share?
Routine & Movement
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On most weekdays, your day looks like …
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On how many days in a usual week do you get any planned movement ?
‍(Walk, yoga, gym, dance, sports, etc.)
Eating pattern & Digestion
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How would you describe your eating preference ?
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Are there any foods you prefer to avoid or don’t eat at all?
(For personal, religious or other reasons)
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On how many days in a usual week do you eat food prepared outside home?
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In the last 1–2 months, have you had any of these?
Sleep, Stress & Cravings
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In the last 2 weeks, how has your sleep been overall ?
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How often do you find yourself eating because of stress, low mood or “just for comfort”?
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What kind of foods do you usually crave or overeat on ?
Goals & anything we missed ...
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What would you like nutrition counselling to help you with right now ?
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Is there anything else you’d like your nutritionist to know – including any obstacles you’re worried about ?
(time, family preferences, travel, cost, motivation, etc.)
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Current Nutritional Assessment

A brief glance

, aged years
Basics
BMI : , which falls in the , range.
Your weight trend (in the last 6 months) shows .
Medications history
You currently seem to be dealing with
You also mentioned these concerns:
Daily Movement
On most weekdays, your day is
In a usual week, you get planned movement on
Eating pattern
You describe your eating preference as
You usually avoids foods like
You eat food prepared outside your home, as frequently as
Stress & Cravings
Overall your sleep, in the last 2 weeks, has been
You report eating to handle stress or just for comfort
You would binge eat these foods
Goals & Obstacles
Your aim in starting nutritional counselling is , and obstacles which you feel you could face are .
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