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New Client Form

Complete and submit this form at least 48 hours before your ZEST Nutrition Initial Assessment.

First name

Last name

Date of Birth

Phone Number

Reason for visit

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Preferred method of contact

Phone Call

Text

How did you hear about us?

Name of Referral Source

Marital Status *

Single / not living with a partner

Living with a partner or spouse

Top 3 Health or Nutrition Concerns

Height

Weight

Recent Weight Gain or Loss?

Yes, weight gain

Yes, weight loss

How many pounds have you gained or lost? In what perod of time?

Desired Weight

How old were you the last time you weighed your desired weight?

List any previous surgeries and the years they were done:

List any current medical conditions:

List past medical conditions and actions taken for treatment:

List any physical activity you do during the week, the duration (minutes), and frequency (times per week)

Do you use tobacco or nicotine?

Yes

Once in awhile

How long have you used tobacco/nicotine?

Do you currently drink alcohol? *

Yes, 1-3 drinks per week

Yes, up to 2 drinks per day or 4-7 drinks per week

Yes, 3-4 drinks per day or 8-21 drinks per week

Yes, 5+ drinks per day, oor 22+ drinks per week

Are you currently following a special diet?

No special diet

Gluten-free

Vegan

Vegetarian

Low carb/diabetic diet

Keto

Low sodium

Other

Other Special Diet

What food allegies have you been diagnosed with?

None

Other

wheat

soy

peanuts

tree nuts

dairy/milk

fish

shellfish

egg

sesame

What other food allergies?

How many meals do you eat per day? (you can choose multiple if it varies)

How many snacks do you eat per day? (you can choose multiple if it varies)

If you have technical issues submitting this form, please complete the PDF version instead and email it to ZESTNutritionService@gmail.com.

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