Download Nutrition Coaching Packet

SET GOALS. BE HEALTHY.
Nutrition Coaching
FLOYD COUNTY BRANCH
CONGRATULATIONS
You have taken an important step toward a healthier life. The following Nutrition Coaching
Packet includes all you need to begin your program.
Please indicate which Nutrition Coaching Package you have chosen:
1 Session Package: $40
3 Session Package: $100
6 Session Package: $190
Please complete the Health Questionnaire, the Food, Liquid and Activity Form (directions
below) and sign the Waiver and Release. After completing your packet, return it to the
front desk along with your payment. All Nutrition Coaching sessions are non-refundable.
Sessions that you purchase must be used within 6 months of purchase date.
Food, Liquid and Activity Form Directions
Fill out for three consecutive days using one log per day. Try to make them as “normal” as
possible so that Tarah gets a true idea of your habits. Be specific and detailed. (i.e. turkey
sandwich is not detailed enough, write 3 oz. turkey, 2 slices of white bread, slice of
tomato, 2 tbsp. honey mustard, etc.). Write down everything that goes into your mouth, no
matter how minute you think it is, even liquids.
Once Packet and Payment are Received
After the packet and payment are received, you will be contacted by Tarah Chieffi, our
nutrition educator to arrange a time for your first appointment. Please allow approximately
five days for contact so she has time to receive the packet and review it.
Your nutrition consultation sessions will be scheduled between Tarah and you. It is the
member’s responsibility to contact Tarah at least 24 hours in advance to reschedule
any session. Failure to adequately contact the nutrition educator will count as a paid
session.
Health Questionnaire
Nutrition Coaching
FLOYD COUNTY BRANCH
General Information
Client name: ____________________________________________
Home phone: ___________________________________________
Date of birth: __________________________________________
Cell phone: ______________________________________________
Gender: __________________________________________________
Address: _________________________________________________
Referred by: ____________________________________________
Email: ____________________________________________________
Health History
Height: ______________________________________________________________________________________________________________________
Current weight/desired weight: ________________________________________________________________________________________
Primary care physician? _________________________________________________________________________________________________
Contact information? __________________________________________________________________________________________
When did you have your last complete physical? _________________________________________________________________
Are you currently seeing other health practitioners? Yes / No
Names and specialties? _______________________________________________________________________________________
Have you had any serious accidents or surgeries? List them here. ____________________________________________
________________________________________________________________________________________________________________________________
How would you describe your health up until this time? _________________________________________________________
Do you have any chronic health conditions? List them here. ___________________________________________________
________________________________________________________________________________________________________________________________
Do you miss much work? Yes / No
If yes, what are the reasons? ________________________________________________________________________________
How have you dealt with your health issues (doctor, medication, alternative care, etc.)?
________________________________________________________________________________________________________________________________
How often do you get sick? ____________________________________________________________________________________________
Does it take you long to recover? __________________________________________________________________________
Present Health Concern
Describe your reasons for seeking nutrition consultation at this time: ______________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are you primary health concerns? _____________________________________________________________________________
What are your symptoms? ______________________________________________________________________________________________
When did these begin? __________________________________________________________________________________________________
Have you been diagnosed by a doctor? ______________________________________________________________________________
Do you have lab test results? Yes / No
Was there anything different or particular about your life at the time of onset? __________________________
________________________________________________________________________________________________________________________________
How did you address these concerns before now? _______________________________________________________________
________________________________________________________________________________________________________________________________
Are you aware of anything that makes your symptoms better or worse? ___________________________________
________________________________________________________________________________________________________________________________
Are there any times of the day when you feel better or worse? _______________________________________________
Do any family members have similar health concerns now or in the past? __________________________________
Do any medical conditions run in your family? _____________________________________________________________________
What prescription/over-the-counter medications are you currently or regularly taking? ________________
________________________________________________________________________________________________________________________________
How long have you been taking them? _____________________________________________________________________
What is the reason for using them? ________________________________________________________________________
Have you seen any positive or negative effects? ________________________________________________________
Who is overseeing the use of these medications? _______________________________________________________
What vitamin, mineral, herbal or other supplements do you regularly take? ________________________________
________________________________________________________________________________________________________________________________
How long have you been taking them? _____________________________________________________________________
What is the reason for using them? ________________________________________________________________________
______________________________________________________________________________________________________________________
Have you seen any positive or negative effects? ________________________________________________________
Who is overseeing the use of these supplements? ______________________________________________________
Do you have gastrointestinal/digestive problems? ________________________________________________________________
How often do you have bowel movements? ________________________________________________________________________
Do you experience constipation… diarrhea… other? ____________________________________________________
Women:
Do you have menstrual periods? Yes / No
Are they painful? _______________________________________________________________________________________________
Do you get PMS? _______________________________________________________________________________________________
Number of days between periods? __________________________________________________________________________
Length of period? _______________________________________________________________________________________________
Do you use contraceptives? Yes / No
What type? _______________________________________________________________________________________________________
Length of use? __________________________________________________________________________________________________
Are you taking hormone replacement therapy? Yes / No
What type? _______________________________________________________________________________________________________
Length of use? __________________________________________________________________________________________________
Do you get up during the night to urinate? Yes / No
If so, how often? _______________________________________________________________________________________________
Men:
Do you get up during the night to urinate? Yes / No
If so, how often? _______________________________________________________________________________________________
Are you experiencing erectile dysfunction? Yes / No
Lifestyle History
What is your living situation (alone, with friend, roommate, relative, partner, spouse, # of children,
pets, etc.)? _________________________________________________________________________________________________________________
What types of movement, physical activities or exercise do you engage in? _______________________________
________________________________________________________________________________________________________________________________
Frequency and intensity? _____________________________________________________________________________________
How much sleep do you get on an average night? ________________________________________________________________
Describe the quality of sleep: ________________________________________________________________________________
How is your energy level: poor, fair or good? ______________________________________________________________________
Does your energy fluctuate during the day? ______________________________________________________________
Do you have quality time with family and friends? ________________________________________________________________
What do you do to relax? _______________________________________________________________________________________________
How much time do you devote to rest, self care, personal time, recreation and/or creativity? _________
________________________________________________________________________________________________________________________________
What do you do for a living? ___________________________________________________________________________________________
Number of work hours per week? ___________________________________________________________________________
Do you like your current job? ________________________________________________________________________________
Have you worked or lived in an environment where you are exposed to pesticides,
chemicals, heavy metals or other pollutants? ____________________________________________________________
Is there much stress in your life? _____________________________________________________________________________________
What causes you the most stress? _________________________________________________________________________
How do you cope with the stress? __________________________________________________________________________
Do you smoke, drink alcohol or use recreational drugs? Yes / No
Types and frequency? _________________________________________________________________________________________
Are you happy in your life at this time? _____________________________________________________________________________
Do you have adequate support? ______________________________________________________________________________________
Diet History
Describe a current typical day’s diet: ________________________________________________________________________________
________________________________________________________________________________________________________________________________
Do you enjoy the food you eat? _______________________________________________________________________________________
Do you have regular meal times? _____________________________________________________________________________________
Where do you usually eat meals? _____________________________________________________________________________________
Do you eat slowly and chew your food well? _______________________________________________________________________
Has your diet changed in regards to your current health concerns? Yes / No
If yes, how has it changed? __________________________________________________________________________________
If yes, what was your diet like at the time your health concerns started? _________________________
______________________________________________________________________________
Have you experienced periods of eating junk foods, restrictive dieting, or binge eating? Yes / No
When, how long? _______________________________________________________________________________________________
How many times do you eat out each week? _______________________________________________________________________
How many times do you eat “fast foods” each week? ____________________________________________________________
Do you reach for certain foods to cope with stress or emotions? Yes / No
Which ones? _____________________________________________________________________________________________________
What are your comfort foods? ________________________________________________________________________________________
Do you use artificial sweeteners? Yes / No
If so, which ones and how often? ___________________________________________________________________________
What is your relationship with sugar (frequency and amount)? ________________________________________________
Describe your typical diet and eating habits while you were growing up: ____________________________________
________________________________________________________________________________________________________________________________
Do you have foods sensitivities, allergies or restrictions? ______________________________________________________
Are you on a special diet? ______________________________________________________________________________________________
How many glasses of water do you drink during a typical day? ________________________________________________
Describe your appetite in the morning, afternoon and night. ___________________________________________________
________________________________________________________________________________________________________________________________
How do you feel if you skip a meal or eat sugary foods? _______________________________________________________
________________________________________________________________________________________________________________________________
Do you crave any of the following foods:
Sweets? Yes / No
Chocolate? Yes / No
Breads? Yes / No
Fatty foods? Yes / No
Salty foods? Yes / No
Dairy? Yes / No
Meat? Yes / No
Other? ____________________________________________________________________________________________________________
How is your digestion? __________________________________________________________________________________________________
After eating, do you feel well nourished and energized or tired and sluggish? _____________________________
_____________________________________________________________________________________
Health Support
What is your desired health outcome? _______________________________________________________________________________
________________________________________________________________________________________________________________________________
Can you imagine being completely healthy? ________________________________________________________________________
How would your life be different? ____________________________________________________________________________________
Would you be willing to make changes in your current diet or lifestyle if you believed it would be
beneficial to your health? ______________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Do you have friends or family who will be supportive of you during your healing process? _____________
________________________________________________________________________________________________________________________________
FOOD, LIQUID AND ACTIVITY FORM
Nutrition Coaching
FLOYD COUNTY BRANCH
Name: ___________________________________________________________________________________________________
Check all that apply:
 Typical Day
Food and Liquid Consumed
 Work Day
 Day off
Portion Size
Breakfast
Lunch
Dinner
Snacks
*1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied)
Time
Date: ______________________________________________________________________________
 Unusual Day
Hunger Level
Before
*Scale: 1-5
Satisfaction
After
*Scale: 1-5
Supplements/
Dosage
Physical Activity
Type and Duration
FOOD, LIQUID AND ACTIVITY FORM
Nutrition Coaching
FLOYD COUNTY BRANCH
Name: ___________________________________________________________________________________________________
Check all that apply:
 Typical Day
Food and Liquid Consumed
 Work Day
 Day off
Portion Size
Breakfast
Lunch
Dinner
Snacks
*1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied)
Time
Date: ______________________________________________________________________________
 Unusual Day
Hunger Level
Before
*Scale: 1-5
Satisfaction
After
*Scale: 1-5
Supplements/
Dosage
Physical Activity
Type and Duration
FOOD, LIQUID AND ACTIVITY FORM
Nutrition Coaching
FLOYD COUNTY BRANCH
Name: ___________________________________________________________________________________________________
Check all that apply:
 Typical Day
Food and Liquid Consumed
 Work Day
 Day off
Portion Size
Breakfast
Lunch
Dinner
Snacks
*1 (not hungry or not satisfied) – 5 (very hungry or completely satisfied)
Time
Date: ______________________________________________________________________________
 Unusual Day
Hunger Level
Before
*Scale: 1-5
Satisfaction
After
*Scale: 1-5
Supplements/
Dosage
Physical Activity
Type and Duration
Waiver and Release
Nutrition Coaching
FLOYD COUNTY BRANCH
Tarah Chieffi provides nutrition information and does not diagnose or treat disease. You
should consult a Physician for diagnosis and before undergoing any dietary or food supplement
changes. Any recommendations you follow for changes in diet, including but not limited to the
use of food supplements, are entirely your responsibility.
In consideration of my participation in Nutrition Coaching, I hereby accept all risk to my health
and of my injury or death that may result from such participation and I hereby release Tarah
Chieffi and the YMCA of Greater Louisville from any liability to me, my personal
representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of
action for loss of or damage to my property and for any and all illness or injury to my person,
including my death, that may result from or occur during my participation in Nutrition
Coaching, whether caused by negligence of Tarah Chieffi or otherwise. I further agree to
indemnify and hold harmless Tarah Chieffi and the YMCA of Greater Louisville from liability for
the injury or death of any person(s) and damage to property that may result from my negligent
or intentional act or omission while participating in the described Nutrition Coaching session.
All of Tarah Chieffi’s communications, including her Nutrition Coaching and her website, make it
clear that her recommendations and writings offer no guaranteed cure for disease.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL
CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY
THAT OCCURS WHILE PARTICIPATING IN NUTRITION COACHING AND IT OBLIGATES ME TO
INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON
AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
Client Name (printed): ______________________________________________ Date: ______________________________________
Client Signature: _____________________________________________________