Personal Touch Nutrition

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Gold Package
GOLD PACKAGE includes a 90 MIN. CONSULTATION and material for clients to take home that highlights some fundamental nutritional suggestions for better health. All clients complete and submit a Consultation Form that provides background information prior to the scheduled Consultation. Consultations cover any questions and/or concerns clients have regarding their health, nutrition, etc. Suggestions and nutritional recommendations are determined ... (Read More)

Platinum Package
PLATINUM PACKAGE gives clients an opportunity for more detailed and specified nutritional guidance. PLATINUM PACKAGE includes 3 appointments and additional material: * 90 MIN. CONSULTATION, described in the Gold Package * PERSONALIZED FOOD PLAN designed for each client's needs and goals * 3RD. FOLLOW-UP APPOINTMENT provides an opportunity for clients to report successes, likes/dislikes approximately ... (Read More)

Please fill out this form and submit it - we will contact you shortly!

First Name
Last Name
Date
Address
City / State / Zip	/ /
Phones
Birthdate
Email	*
* this information is required

Please complete the following information with brief, but specific answers. Type “NA” if a question is not applicable to you. Add any additional information you think is important at the end of the form.
Age		Sex
Height		Weight

Food Plan Goals
Whch diets have you tried? (I.E. Atkins, Weight Watchers, Zone, Vegetarian, Macrobiotic, Etc.)
What were the results?
Previous health conditions
Current health conditions
Medications
Vitamins/Supplements

Workplace & home schedule — please go through a typical day from wake-up to bedtime by the times of day (i.e. 6 a.m. Wake up. 7 a.m. Go to gym/work out. 8 a.m. Breakfast. 9 a.m. Work. 11:30 a.m. Lunch….etc.)
5am		6am
7am		8am
9am		10am
11am		12pm
1pm		2pm
3pm		4pm
5pm		6pm
7pm		8pm
9pm		10pm
11pm		12am

Exercise Habits/Routine
Do you usually: eat lunch at home? pack lunch? go out to lunch?
What (sit-down) restaurants do you like/go to (with family, friends, co-workers, etc) and how often?
Fast food restaurants (and how often)?
Do you like or dislike to cook?

Which kitchen appliances do you have?

Do you and your spouse/family have the same eating patterns? How do they differ?
Where and how often do you buy groceries?
Do you ever buy organic foods? If 'yes' then which organic foods/products do you buy?

Below is a list of food categories. For each category list the foods that you frequently eat and/or buy.

Meat:

Poultry:

Seafood/Fish:

Dairy:

Bread:

Pasta:

Grains:

Cereal:

Sweets (baked goods/cookies, cake):

Candy—do you prefer fruity (skittles) or chocolate (M&Ms):

Snack foods (Salty? Sweet?):

Below is a list of beverage categories. For each category list the beverages you drink and the approximate amount per day of each:

Water:

Coffee (Black? Creamer? Sweetener? Latte? Etc.):

Tea (Herbal, Caffeinated, Decaf, Etc.):

Soda (Regular, Diet, Caffeine-free, Etc.):

Milk (Dairy—2%, 1%, Skim, Etc.— Soy, Rice, Etc.):

Juice :

Alcohol:

Here’s the fun and easy part! Tell me what you like and don’t like. If you like all of the foods in a category, then write “all” in the “like” column. But, if you are a bit more particular, then be specific and write your dislikes and neutrals in the appropriate columns. List any specific items you eat by the categories, as well. For example, “oils”: olive, sesame, flax, etc.
	Like	Neutral	Dislike
Fruits
Veggies
Beans
Tofu
Eggs
Dips, Sauces, Spreads
Herbs, Spices
Nuts, Seeds
Oils
Condiments
Sweetners

Additional comments or information you want me to know prior to our first consultation