Skip to content

EN

RU

About
Services
Contact
Blog

About
Services
Contact
Blog

EN

RU

Book Consultation

Health & Nutrition Intake Form

Personal Information

First Name

Last Name

Email Address

Phone

GenderMaleFemale

Date of Birth

Height (cm)0 / 3

Weight (kg)0 / 3

Main Client GoalWeight lossWeight gainMaintain weightEnergyDigestionSkin & hairGeneral wellnessOther

Medical History

Chronic diseasesselect all that applyNoneCardiovascularRespiratoryGastrointestinalEndocrineReproductive systemOther

Hereditary predisposition / family historyNoneDiabetesCardiovascular diseaseHigh cholesterolThyroid diseaseObesityCancerOther

Food allergyNoYes

Food intoleranceNoneGluten / cerealsLactose / dairyOther

Are you currently taking medications?NoYes

Laboratory Documents

DocumentsProvide all available laboratory documents & tests like: Blood & urine, Glucose metabolism, Lipid profile, Liver & proteins, Kidney / metabolic, Vitamins & minerals, Intolerance, Thyroid, Additional — age 45+

Drag and Drop (or) Choose Files

Daily Routine

Water intake per day<0.5 L0.5–1 L1–1.5 L1.5–2 L2–2.5 L2.5+ L

Sleep duration<5 h5–6 h6–7 h7–8 h8–9 h9+ h

Sleep qualityPoorFairGoodVery good

Smoking / vaping / alcohol

SmokingNeverRarelySometimesOftenDaily

VapingNeverRarelySometimesOftenDaily

AlcoholNeverRarelySometimesOftenDaily

Average daily steps<3,0003,000–5,0005,000–8,0008,000–10,00010,000+

Training

FrequencyNever1x/week2-3x4-5x6x+

Duration<30 min30–45 min45–60 min60–90 min90+ min

Type

Goal

Meal Schedule

Breakfast

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Morning snack

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Lunch

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Afternoon snack

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Dinner

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Late / night eating

Do you usually have this meal?YesSometimesNo

Usual time

Hours

Minutes

PortionSmallMediumLarge

What do you usually eat and drink?

Food Frequency

VegetablesNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Leafy greensNeverRarely1–3x/week4–6x/weekDailySeveral times/day

FruitNeverRarely1–3x/week4–6x/weekDailySeveral times/day

BerriesNeverRarely1–3x/week4–6x/weekDailySeveral times/day

LegumesNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Whole grains / cerealsNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Bread / pastaNeverRarely1–3x/week4–6x/weekDailySeveral times/day

EggsNeverRarely1–3x/week4–6x/weekDailySeveral times/day

FishNeverRarely1–3x/week4–6x/weekDailySeveral times/day

SeafoodNeverRarely1–3x/week4–6x/weekDailySeveral times/day

PoultryNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Red meatNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Processed meatNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Dairy productsNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Fermented dairyNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Nuts& seedsNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Sweets / dessertsNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Fast foodNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Fried foodNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Salty snacksNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Sugary drinksNeverRarely1–3x/week4–6x/weekDailySeveral times/day

Eating Behaviour

How often do you overeat?NeverRarelySometimesOftenDaily

Do you eat when stressed, sad or bored?NeverRarelySometimesOftenDaily

Do you skip meals?NeverRarelySometimesOftenDaily

Do you eat at night?NeverRarelySometimesOftenDaily

Do you intentionally fast or severely restrict food?NeverRarelySometimesOftenDaily

Do you experience strong cravings for sweets?NeverRarelySometimesOftenDaily

Eating speedVery slowSlowModerateFastVery fast

Foods or situations that trigger overeating

Diet & Weight History

Have you tried diets before?NoYes

Have you used supplements/products for weight loss?NoYes

Other weight-loss methodsNoneMedicationFastingPrograms/coachingProceduresOther

When and under what circumstances did weight gain begin?

Age0 / 2

Details

Context at that time

Personal lifeStableDifficult periodMajor change

Work/studyStableStressfulMajor change

Financial situationStableDifficult periodMajor change

How did your weight change?GraduallyRapidlyFluctuated

Have you experienced a weight plateau?NoNot sureYes

Lifestyle & Weight-Related Factors

Which lifestyle factors may affect your weight or health?NoneSedentary workStressPoor sleepIrregular scheduleFrequent travelNight workSocial eatingAlcoholOther

Which eating habits may contribute?NoneLarge portionsSnackingSweetsFast foodLate eatingSkipping mealsEmotional eatingSugary drinksOther

When are you most tempted by less nutritious food?StressFatigueSocial eventsTravelWeekendsEvening/nightPMS/menstrual periodHunger after skipped mealOther

Food Preferences & Restrictions

Favorite dishes / foods

Disliked foods

Religious, cultural or ethical dietary restrictionsNoYes

Typical Day

HTML

Describe one real, typical day from waking until bedtime. Include all meals, snacks, water, coffee, tea, alcohol and other drinks.

Wake-up

Time

Hours

Minutes