CLIENT ASSESSMENT FORM 1

Personal Goals, Motivation and Stage of Readiness

My overall health goals are:

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My physical performance goals are:

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If I could change three things about my health and nutritional habits, they would be…

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2. ______________________________________________________________________________
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3. ______________________________________________________________________________
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4. ______________________________________________________________________________
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The biggest challenge(s) to reaching my nutrition goals is/ are:

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In the past, I have tried the following techniques, diets, behaviours, etc. to reach my nutrition goals…

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Do you feel you’ve always had a weight problem? Yes No

If yes, around what age did you first notice that you had gained weight? _________________________
What do you feel your weight gain was caused by?

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What diets have you tried in the past?

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Have you ever had any health problems as a result of dieting? Yes No

If yes, what problems?

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Please list any surgeries you've had:

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On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the
following:

To improve your health, how ready/willing are you to… 1 2 3 4 5

Significantly modify your diet

Take nutritional supplements each day

Keep a record of everything you eat each day

Practice relaxation techniques

Engage in regular exercise/physical activity

 Have periodic fitness tests / anthropometric assessments to assess progress

Wellness Goals:
Indicate which health and fitness goals interest you:
❐ Weight management
❐ Increased strength and muscle mass

❐ Increased endurance

❐ Rehabilitation of muscle or joint injury

❐ Advice on supplementation based on my health and dietary practices

❐ Other: (Please describe) ___________________________

Client’s name: ______________ Contact number: _________________

Client’s signature: _________________ Date: ________________

Client’s Guardian signature: _____________________ Date: ________________

(If under 18)

Counsellor’s signature: _________________________ Date: ________________