Online Assessment

First Name (required)


Last Name (required)


Your Email (required)


Phone


Address


Age


Have you seen a dietitian in the past?

 yes no

If yes, was it helpful? Why or why not?


List any diets you have tried (commercial diet programs, from books, and those that you have developed yourself). Give a brief description of each diet.



Do you skip meals?
 yes no


If yes, which meals do you skip and how often?


How many times per week do you eat at restaurants?


Weight History


Height


Current weight


Please describe your exercise routine and amount of physical activity (type, frequency, time).


Please mention on a scale of 1 to 10 how CONFIDENT you are that you can change your eating behaviors


Please mention on a scale of 1 to 10 how MOTIVATED you are that you can change your eating behaviors


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If you have questions, please contact Jessica Faissal by phone at +9613037129 or by email at jessfaissal@gmail.com