Initial Assessment

Food and nutrition questions for my dietitian:
I would like to visit with the dietitian today because:
My food and nutrition related goals are:
If I could change 3 things about my health and nutritional habits, they would be:
The biggest challenge(s) to reaching my goals is/are:
In the past, I have tried the following techniques, diets, behaviors to reach my goals:
Please list any MAJOR past medical and surgical history (Year and describe):
Please list any medication, supplement intake (Name, dose, frequency):

Physical Activity

Rows	Type/Intensity (Low-Moderate-High)	# days/week	Duration
Stretching/yoga
Cardio/aerobics (walking, jogging, biking)
Strength-training (weight lifting, pilates, yoga)
Sports/LeisureFriendliness
Other (describe)