Nutrition Assessment

Nutrition & Wellness Assessment

If interested in learning more about how our services can help you, please complete the following information and print on your home computer. You can then mail your information to:

Nutrition Advantage

4406 Pheasant Hill Dr.

Deerfield, WI 53531

Tina will then personally contact you to discuss how her services can help you and your family.

Name: Phone:

E-mail Address:

Age: Sex: Male Female

Current Weight: Lbs. Height: inches

Daily Activity Level (Does not include exercise): Low Medium High

Frame Size: Small Medium Large
Or wrist circumference in inches:

Note: The best way to judge your frame is by the relative width of your wrist. If the middle finger and thumb of your opposite hand can encircle your wrist comfortably, your frame size is medium.

1. I would describe my lifestyle as (put an "x" in the box that best describes you):
Fast-paced, with a high-stress job. I rarely have time for myself.
Busy mother/father at home. I handle most of the parenting responsibilities.
Erratic! I do not appear to be consistent in my life goals. I generally sabotage most of my attempts at lifestyle changes.
I am content in my current lifestyle, with the exception of one behavior area which I am committed to changing.

2. I exercise:
Rarely.
1-2 times per week.
3-4 times per week.
5 or more times per week.

Type of exercise (choose from the drop down list)
Length of time each session (choose the closest time from the list)

3. I would describe my eating pattern as:
Late-night binge eating. I do most of my eating at night and rarely eat breakfast.
Starve/binge eating. I generally do well for several days, but due to deprivation I binge which leads to a cycle of starvation. I rarely eat regular meals as a result.
Compulsive eating. I generally eat due to stress or due to my feelings. I eat to "stuff" my feelings so I do not have to deal with them. I generally ease my emotions with high-fat or sugary foods.
Well-balanced w/ the exception of some problems with portions and calorie control (or some other minor area of concern such as snacking, etc.).

4. I would like to modify my diet to:
Lose weight and look better.
Be a healthier person and have more energy.
Comply with my physician's diet order.

5. What services would you like?

6. What special dietary advice have you received from a physician?

Putting Your Best Self Forward