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holistic Nutrition Assessment

Consult Form

Name

First Name

Last Name

Gender

Female

Male

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

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Date of Birth & Age

Height & Weight

What are your health objectives ? What would you like to learn and gain from working with a nutrition consultant? (i.e. how foods affect an ailment, understanding of how the body works, lifestyle improvement, etc.)

Your Motivations: What Inspires YOU to be healthy?

Assess your Physical Activity Level

Option 1: Sedentary- Typical daily living activities (e.g. household tasks, walking to the bus)

Option 2: Low Active- Typical daily living activities PLUS 30 - 60 minutes of daily moderate activity (e.g. walking at 5-7 km/h)

Option 3: Active- Typical daily living activities PLUS At least 60 minutes of daily moderate activity

Option 4 Very Active- Typical daily living activities PLUS At least 60 minutes of daily moderate activity PLUS An additional 60 minutes of vigorous activity or 120 minutes of moderate activity

Stress Levels (scale of 1-10) Please indicate your average level of stress on a typical day 1=Low Stress 10= Highest Level Stress

Medical History: Please indicate any family health history concerns as well (heart disease, cancer, ADHD, diabetes, depression etc)

Please list all medical issues and include any medications you are currently taking, including any taken in the past 24months

Please describe your dietary history (do you consume eggs, dairy, meat etc)

Please list any food allergies or intolerances

Do you have any dietary restrictions?

What are your favourite foods? What are your food aversions/least favourite foods?

How much water do you consume per day? Caffeine? Alcohol?

Describe any diet habits or patterns you are aware of: (no breakfast, eating late, snacking when bored etc)

Describe dieting history or any disordered eating patterns? (i.e. yo-yo dieting, calorie restriction, weight gain)

Environmental Questions: What kind of cleaning products do you use? (eco-friendly or non-toxic, generic brands, perfumes? Think of what's in your kitchen, laundry, bathroom, dusting, floors)

What kind of personal care products do you use? Make-up, creams, shampoo/conditioners, body wash soaps etc.

Does your home feel like a place or rest and relaxation? Calming and organized? Or chaotic and stressful? Do you live in an area of high traffic and pollution? Do you have outdoor space, if so what kind? Balcony, trees, yard, garden?

Kitchen Skills: Do you cook for yourself or buy premade or order food regularly? How often and why?

Do you meal prep? If so, what kind of foods/meals do you prep? How much time per week would you like to spend on meal prep?

Self-care: What does self-care look like for you?

How do you like to de-stress?

Consent

I acknowledge that the purpose of this program is to help me improve my health, wellness and lifestyle. I am employing the services of Erika Vipond, Certified Holistic Nutritionist (CHN), so that I can obtain information and guidance about health factors within my own control (diet, hydration, lifestyle, fitness, wellness and other various lifestyle behaviours) in order to help support my health and wellness. I understand that Erika Vipond is a nutritional educator and does not dispense medical advice nor prescribe treatment.

Please check box to agree