Nutrition with Chelsea In-Person Session Form

Please answer the questions below to the best of your ability. This information will give me a clearer idea on how to best support you. Thank you!

Name

First Name

Last Name

What are your current challenges with food or lifestyle?/What made you interested in nutrition & mindset coaching?

What are you most interested in learning more about/what would be valuable to take away from our time together?

Have you worked with a coach or nutritionist before? If yes, what was most helpful, or, what was lacking?

To the best of your ability, describe your current relationship with food. For example, how do you *feel* around food in terms of your mindset & your relationship to it.

Do you look at food in terms of rules? Meaning, labeling things as “good” or “bad” “allowed” or “off-limits” and/or following restrictions under a specific diet, etc.

Up until this point where have you received information about health & nutrition? And if applicable, are there a few major recommendations you believe you should try to stick to from that information?

What does health, or being healthy mean to you?

On a scale from 1-10 how is your energy throughout the day?

On a scale from 1-10 how well do you sleep?

Do you eat breakfast? If yes, what time on average & describe a common breakfast to the best of your ability.

Do you eat lunch? If yes, what time on average & describe a common lunch to the best of your ability.

Do you eat dinner? If yes, what time on average & describe a common dinner to the best of your ability.

Do you eat snacks? If yes, what time(s) on average & describe a common snack to the best of your ability.

Do you get hungry mid-morning?

yes

Do you get hungry mid-afternoon?

yes

Do you ever get hangry (irritable, shaky, ravenous)?

yes

Do you have cravings? If yes, for what mostly?

How do you usually feel after you eat? For example, sluggish & tired? Bloated & gassy? Energized & light? Or, other.

What are your favorite foods?

What are your least favorite foods?

Are you a slow, moderate, or fast eater?

Are there any minor or major health issues or concerns you would like to share with me before we speak?

Anything else you would like me to know?

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Nutrition with Chelsea In-Person Session Form