Nutrition Questionnaire

To schedule a Nutrition Coaching appointment, please complete and submit this questionnaire. Also, print and complete the food log provided on the previous page.

Questions? Contact Ethan Mattingly, by phone: 502-852-8255 or email our service account.

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BACKGROUND INFORMATION

What sex were you assigned at birth?  (Check One) This is for assessing nutritional needs of your individual body and is not shared with anyone
Where do you live?  
Off Campus Select one
Referred By:  
Have you seen a Dietitian before?
Nutrition Assessment
PHYSICAL ACTIVITY ASSESSMENT:
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How important is this change to you?
How confident are you in making this change?
In cooperation with Campus Health, are you in agreement that this questionnaire will be scanned into your medical chart?