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Consultation Form

Consultation Form

PERSONAL INFORMATION


First name

Phone



INITIAL ASSESSMENT


Date

Current Weight



CURRENT LIFE STYLE


Wake Up Time




Typical Breakfast




Typical Dinner




Average Daily Calories

Alcohol/week



MEDICAL ISSUES/OTHER


Cardiovascular disease

Chronic kidney or liver issues

Diabetes

High blood pressure

Pregnancy

Respiratory disorders

Significant psychological challenges

Other medical issues that may be aggravated by altered physical activity or diet

Allergies/Intolerances

Medications

Injuries

Food Dislikes



Healthy Eating & Weight Loss Balance Evaluation


A -  About Overall Healthy Eating Status


1)   My energy level meets all of my daily needs

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2)   I enjoy a diet with a variety of healthy foods

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3)   I eat organic food whenever possible

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4)   I avoid eating highly processed foods

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5)   I eat my meals and snacks around the same time every day

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B -  About Water Consumption


6)  I drink at least three litres (12 cups) of water per day

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7)  I avoid drinking 3 or more caffeinated beverages/day

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8F)  Females: I consume between 0 - 2 alcoholic beverages per day

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8M)  Males: I consume between 0 - 3 alcoholic beverages per day

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9)  I avoid consuming sugar-filled beverages (i.e. pop, store-bought juice, energy drinks,etc.,) on a daily basis

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10)  I enjoy 1 - 2+ non-caffeinated herbal teas per day

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C -  About Protein Consumption


11)  I consume between 0 - 2 servings of animal protein everyday (i.e. chicken, beef, eggs, etc)

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12)  I consume mostly high quality whole food protein sources daily (i.e. beans, lentils, raw nuts and seeds, lean meats, etc)

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13)  I consume 0 - 2 servings per week of deli meats, luncheon and highly processed packaged products or meals

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14)  I consume 0 - 2 servings of dairy products daily (i.e. milk, yogurt, cheese, etc)

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15)  I consume 2+ servings of plant protein everyday (i.e. nuts, seeds, legumes, etc)

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D -  About Fat Consumption


16)  I consume sources of omega 3 everyday (i.e. salmon, flaxseeds, hemp, etc)

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17)  I eat between 0 - 2 servings per week of highly processed fatty foods (i.e. margarine, french fries, chocolate bars, pizza, potato chips, etc)

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18)  I consume only lean cuts of meat versus fatty cuts

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19)  I consume 0 - 2 servings of fast food per week (i.e. servings that are not home cooked or prepared at home)

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20)  I understand how to identify hidden fats in foods and food products

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E -  About Carbohydrate Consumption


21)  I eat 3+ servings of vegetables per day

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22)  I consume at least 1 - 2 servings of fruit everyday

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23)  I eat between 0 - 2 servings of 100% whole grain products daily

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24)  I understand the importance of fibre and consume fibre daily

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25)  I avoid eating highly processed foods and drinks (i.e. cereals, crackers, white pastries, food and drinks with added sugars, etc)

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F -  About Micronutrient Consumption


26)  I eat my vegetables lightly steamed and not overcooked

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27)  I eat raw vegetables on a daily basis

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28)  I eat dark leafy greens everyday

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29)I consume super foods daily (quinoa, kale, avocado, legumes, turmeric, ginger, garlic, sprouted wheat grass and nuts/seeds, etc)

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30)  I eat at least seven fruits per week

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G -  About Weight Management


31)  I read food labels and I understand how to differentiate the healthy from the unhealthy ingredients found in the package foods that I eat

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32)  I make an effort to not skip meals (especially breakfast)

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33)  I eat at least two out of three meals at home (or homemade) everyday

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34)  After a meal I feel comfortable and not as though I've overeaten

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35)  I stop eating at least two hours before bed

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H -  About my Healthy Mindset


36)  I am happy with my body weight and body composition right now

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37)  I have a positive self-image

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38)  Overall I feel that I am on the right path and I am a positive healthy eating role model for those around me

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39)  I learn from my mistakes and develop strategies for personal growth including asking for help from family and/or colleagues

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40)  I am happy, enjoy life and feel that I have a good support system around me

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I -  About my Activity & Exercise Routine


41)  I am able to lift heavy items in my day-to-day life (groceries, children, household items, etc)

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42)  I have a routine exercise schedule

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43)  I am able to move my body with minimal pain and limitation

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44)  I physically move often throughout the day

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45)  I exercise most days of the week which includes cardiovascular exercises (5 moderate hours or 2.5 vigorous hours/week), strength training exercises (3 or more times/week) & flexibility/stretching exercises (4 or more times/week)

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