Rachael Schwartz Nutrition
About
Meet Rachael
My Philosophy
Work With Me
Nutrition Coaching
Testimonials
Recipes
SHOP
Contact
About
/
Meet Rachael
My Philosophy
Work With Me
/
Nutrition Coaching
Testimonials
Recipes
/
SHOP
/
Contact
/
Eat Real, Sweat Hard, Discover Your New Normal
Prescreen Form
About
/
Meet Rachael
My Philosophy
Work With Me
/
Nutrition Coaching
Testimonials
Recipes
/
SHOP
/
Contact
/
Prescreen Form
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Primary phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Relationship status (Name)
Children? (Names/Ages)
Pets? (Names)
Occupation
*
Hours Per Week
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Referred By
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PERSONAL HEALTH HISTORY
What is your main reason for seeking help/guidance from a nutrition coach?
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What is your height?
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What is your current weight (in pounds)?
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How often do you weigh yourself?
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What is your desired weight (in pounds)?
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Do you have any medical conditions that you would like me to know about?
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List all supplements you're currently taking including vitamins, herbs and minerals.
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Do you experience digestive difficulties? If yes, please explain. (i.e. bloating, gas, constipation)
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How often do you have a bowel movement? What time of day usually?
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FOOD ALLERGIES / INTOLERANCES
List of Food Allergies/Intolerances and Reactions
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If yes, do you avoid these foods? Please explain.
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Do you have any dietary restrictions or follow any special diets (Ex. Vegan Diet, Kosher Diet, etc.)?
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Have you ever experienced an eating disorder or disordered eating? If yes, please explain.
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Have you ever met with a dietitian or nutritionist before?
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Yes
No
How was your experience? If it was negative, what didn't you like about the experience? If it was positive, what did you find helpful?
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Have you ever dieted before? If so, what have you tried and how did it work?
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EXERCISE
Describe your current physical activity routine, if you have one (How often do you do these? amount of time/days per week, also try to give speed of machines/intensity level)
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DIET
What are the biggest barriers for you when following a diet? What do you feel are your worst eating habits? For example, the "all or nothing" mentality, binge restriction, etc.
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Is there anything that will get in the way of following a treatment plan in order to achieve results?
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What do you think has been preventing you from achieving your goals?
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Where would you like to be 6 months from now regarding your health and fitness goals?
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What is your level of commitment to improving your health
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1 = Lowest, 10 = Highest
1
2
3
4
5
6
7
8
9
10
TRACKING PROGRESS
I highly encourage taking pictures of front, side, back to track progress every two weeks. These can be extremely helpful since sometimes it can be hard to see daily changes on your own
Would you be open to taking these pictures?
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Yes
No
Would you be open to sharing them with me regularly
*
Yes
No
Would you be open to me sharing them on my website and/or social media platforms to motivate and encourage others?
*
Yes WITH Face
Yes WITHOUT Face
Maybe
Never
Thank you, please proceed to next form
