Nutrition pre-screening form
Hi everyone,
as part of my online nutrition studies, I've been asked to develop a pre-screening form for potential clients should I choose to get into nutrition professionally someday. I'm not actually thinking so much in this direction right now so this exercise is purely theoretical in my case, but it's still required of me anyway.
The idea is to capture a broad overview of someone's physical statistics, personal habits and living circumstances with regard to how each might have an impact on their personal health as it currently stands. Basically, a set of initial questions that a nutritionist or similar might look to ask each of their clients in advance of their first face-to-face meeting.
It's not meant to be so detailed as to replace face-to-face meetings altogether, but not so limited that it results in the same first questions being asked of each client at the face-to-face meetings. This is what I've come up with so far, and I'd appreciate any general feedback anyone might have to offer. Is there anything obvious that I might be missing, and/or I asking too much in other areas? What do we reckon?
Note that I'm not asking anyone to reply with their actual answers to these questions, just for feedback on the set of questions themselves please.
Thanks in advance.
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Personal identity
1. Name
2. Gender
3. Date of birth
4. Ethnicity
5. Contact email
6. Contact phone number
7. Preferred method of contact
8. Occupation
9. Average hours worked per week
10. How many others do you live with?
Measurements and medical notes
11. Height (units)
12. Weight (units)
13. Waist circumference (units)
14. Any pre-existing medical conditions (if yes, what pre-existing medications, if any)?
15. Any family history of health issues?
16. Any allergies/intolerances/imbalances (if yes, what supplements do you take, if any)?
17. Most recent readings (include units, date taken and name of issuing GP):
Blood pressure:
Blood glucose:
HbA1c:
Triglycerides:
HDL cholesterol:
LDL cholesterol:
Lifestyle factors
18. How would you characterise your overall eating pattern e.g. standard Western, low fat, Mediterranean, low carb, ketogenic, vegetarian, vegan?
19. Provide a typical example of foods eaten across a given week (think of a food diary):
20. How often do you eat per day (include any regular snack times such as morning/afternoon tea, supper)?
21. How long do you typically go without eating in a day (e.g. overnight)?
22. Describe typical exercise routine(s) and duration across a given week?
23. Do you carry any physical injuries that may prevent/impair certain movements?
24. How many hours of sleep do you get per night, on average?
25. Do you drink alcohol (if yes, what type(s) and how much)?
26. Do you smoke (if yes, how many/day)?
27. Any history of particular diets or other health improvement initiatives, and if yes, what/when? Any history of weight loss/gain as a result, and if yes, how much?
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