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ABOUT
Schedule An Appointment
Visia Complexion Analysis
Contact Us
Terms & Conditions
Privacy Policy
MEMBERSHIP
Become a Member
Members Portal
Payment Plans
SERVICES
Non-Invasive Cosmetic Treatments
Medical Services
Wellness Services
SHOP
Shop Skin Care
December Specials
Gift Certificates
BLOG
GALLERY
ABOUT
Schedule An Appointment
Visia Complexion Analysis
Contact Us
Terms & Conditions
Privacy Policy
MEMBERSHIP
Become a Member
Members Portal
Payment Plans
SERVICES
Non-Invasive Cosmetic Treatments
Medical Services
Wellness Services
SHOP
Shop Skin Care
December Specials
Gift Certificates
BLOG
GALLERY
Client Nutrition Questionnaire
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 2
Name
*
First
Last
Age
Usual Weight (lbs)
Goal Weight (lbs)
A personal health goal of mine is:
I'm most interested in learning:
My nutrition knowledge is:
Very Good
Good
Average
None, but I want to learn more
Have you ever had a consult with a dietitian or nutritionist?
Yes
No
Have you ever tried structured programs to lose weight? (Weight Watchers, Jenny Craig, etc.)
Yes
No
Were you successful?
Yes
No
If Yes, how much weight did you lose?
If Yes, how long did you keep it off?
Have you ever tried your own plan or diet for weight loss?
Yes
No
If Yes, how much weight did you lose with your own plan or diet?
If Yes, how long did you keep it off using your own plan or diet?
Do you have any food allergies?
Yes
No
Don't Know
If yes, please explain below what you are allergic to?
Do you have any food intolerances or strong dislikes? Please explain
Do you take any vitamins or supplements? Please explain
How would you describe your exercise habits? Check all that apply:
I enjoy my exercise routine and usually stick to it
I want to improve my exercise habits but things get in the way
I really don’t like to exercise
I have physical conditions that limit my exercise
I exercise:
0-2x/week
3-4x/week
5-7x/week
0-30 minutes/session
45-60 min./session
60+ min/session
Next
The following questions relate to your typical eating habits:
How many meals do you eat daily?
1
2
3
5-6 Small
Do you like to snack? If Yes, what are your favorite snacks?
Do you drink alcohol? If Yes, how much?
I usually go out or take out meals (restaurant or fast food) Check all that apply
1-3 days a week
3-5 days a week
5+ days a week
1-2 times a month
2-5 times a month
7 or more times a month
How many days a week do you eat home cooked meals for dinner?
Who does the shopping and cooking for the family?
What time do you usually take lunch at and for how long?
I often skip breakfast:
Yes
No
Sometimes
I travel often:
Yes
No
Do you ever eat for reasons other than hunger? Please check all that apply
relaxing/reward
upset
boredom
tired
stress/anxiety
social custom
other
What foods would you describe as your staple foods (eat almost on a daily basis)
Number of times per week you eat the following Traditional American cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times per week you eat the following Italian cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times per week you eat the following Mexican cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times per week you eat the following Chinese/Japanese/Thai/Korean cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times per week you eat the following Asian/Indian cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times per week you eat the following Indian Vegetarian cuisine:
select # of times
0
1
2
3
4
5
6
7
Number of times you eat something other than what is listed above:
select # of times
0
1
2
3
4
5
6
7
Please review the HIPPA Policy below and sign your name in the field for your consent
*
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