Healthy Eating Assessment Form

Gazelle Nutrition Lab / For Clients / Healthy Eating Assessment Form

Name*
Birth Date
MM slash DD slash YYYY
Age
Please fill out the following information to the best of your knowledge. Certain items may not apply to you. If they do not, please leave those sections blank.
Medical Information
Physician or medical provider:
Name Address Phone
Other Health Care Providers
(E.g. physiotherapist, chiropractor, naturopath, athletic therapist, massage therapist):
Current medications:
Medical history:
Laboratory values
If you have had blood work done recently this is great. Please provide any numbers you have for the indices in the table below.
Date blood work was taken:
MM slash DD slash YYYY
CMP (Comprehensive Metabolic Panel)
CBC (Complete Blood Count)
Other
Na (Sodium)
WBC (White Blood Cell Count)
Mg (Magnesium)
K (Potassium)
RBC (Red Blood Cell Count)
Zn (Zinc)
Cl (Chloride)
Hct (Hematocrit)
Vit D (Vitamin D)
BUN (Blood Urea Nitrogen)
HgB (Hemoglobin)
B12 (Vitamin B12)
Cr (Creatinine)
MCV (Mean Cell Volume)
Folate
Alb (Albumin)
MCH (Mean Corpuscular Hemoglobin)
Ferritin
Glc (Glucose)
Corpuscular Hemoglobin
Fe (Iron)
CO2 (Carbon Dioxide)
MCHC (Mean Corpuscular Hemoglobin Concentration)
TIBC (Total Iron Binding Capacity)
Ca (Calcium)
Saturation
ALP (Alkaline Phosphatase)
TSH (Thyroid Stimulating Hormone)
AST (Aspartate Aminotransferase)
Estradiol
ALT (Alanine Aminotransferase)
Estrone
Alb:Cr (Albumin to Creatinine Ratio)
Additional comments
Physical Status
Height:
Current Weight:
Usual Adult Body Weight:
Highest body weight
at age
Lowest body weight
at age
Body composition
If you have had your body fat and muscle mass estimated by devices such as skinfold calipers, the Bod Pod, or bioimpedance analysis please provide the information below.
Lean Body Mass:
%
Body Fat:
%
Date measured:
MM slash DD slash YYYY
Lifestyle Information
Are you active?:
- Yes
- No
In which sports do you participate:
List sports and how often you do each sport
Diet
Vitamin and mineral supplements:
Weight loss, herbal or sports supplements:
Food allergies:
Food dislikes:
Describe your daily eating habits:
Alcohol Frequency:
Alcohol Quantity:
Alcohol Type:
How often do you eat at restaurants or consume take-out or fast food?
How often do you eat snack foods? Type?
Describe your typical eating environment (e.g. alone, with a spouse or roommate, in car, at desk):
What is your primary goal for your nutrition counselling experience overall?
What 3 nutrition changes do you think should you make starting today?
1. 2. 3.
Preferred strategy for nutrition intervention:
- Day-to-day meal plan
- Food choices (e.g. 2 starches, 3 protein) + selections
- General guidelines (e.g. eat 6 vegetable servings/day)
Other comments:
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Phone
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Healthy Eating Assessment Form

Medical Information

Laboratory values

Physical Status

Body composition

Lifestyle Information

Diet

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Welcome to Gazelle Nutrition

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Healthy Eating Assessment Form

Medical Information

Laboratory values

Physical Status

Body composition

Lifestyle Information

Diet

Shop

Follow Us On Instagram