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Goals & Readiness Assessment
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What specific nutrition-related concerns or goals do you have?
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How do you envision SHINES nutritional support helping you achieve them?
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My food and nutrition-related goals are...
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My overall health goals:
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The biggest challenge(s) to reaching my nutrition goals:
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In the past, I have tried the following techniques to reach my nutrition goals (e.g.: diets, behaviors, etc.)
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On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:
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Modify your diet
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Take nutritional supplements
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Keep a record of everything you eat
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Modify your lifestyle (e.g.: work demands, sleep habits, physical activity)
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Practice relaxation techniques
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Engage is regular exercise/physical activity
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Have periodic lab tests to assess your progress
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Please list the medications you are currently taking (prescription and OTC)
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Type of Medication, Brand, Dosage, How often?
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Type of Medication, Brand, Dosage, How often?
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Type of Medication, Brand, Dosage, How often?
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Type of Medication, Brand, Dosage, How often?
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Do you take any vitamins or other dietary supplements? If yes, list below
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Type of Supplement, Brand, Dosage, How often?
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Type of Supplement, Brand, Dosage, How often?
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Type of Supplement, Brand, Dosage, How often?
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Type of Supplement, Brand, Dosage, How often?
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Weight History
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Would you like to be weighed today?
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Current Weight
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Current Height
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Desired weight
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Highest adult weight? and when?
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Weight one year ago
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Any recent changes in weight you are concerned about?
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If recent change in weight is a concern please explain
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Has your weight changed in the last year?
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If weight has changed in past year, what was your weight one month ago? 6 months ago?
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Usual Food Intake
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Have you recently changed the types of food you eat?
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If previous answer was yes, please explain
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Please check any of the following problems that have kept you from eating adequately over the past 2 weeks
• • •
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If you selected "Pain in General" on last prompt please explain
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Digestive History
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Do you associate any digestive symptoms with eating certain foods?
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If previous answer was yes, please explain
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How often do you have bowel movement?
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If you take laxatives, what type, brand, and how often?
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Meal Preparation
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How many meals do you eat away from home on weekday? (Breakfast, Lunch, Dinner)
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How many meals do you eat away from home on weekends? (Breakfast, Lunch, Dinner)
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List restaurants where you often eat
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Exercise & Other Lifestyle Habits
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What type of exercise do you most enjoy? (e.g.: walking, running, swimming)
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What are your leisure activities/hobbies?
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Sleep
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Do you wake up feeling rested?
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Do you take naps?
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How would you rate your sleep?
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Sleep too much
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No need for sleep
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Do you stay up later than you think you should?
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What keeps you from going to bed?
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