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Optimal You Wellness Clinic
Client Nutritional Assessment & Intake Form
Personal Information
Client Name
Date
Phone Number
Email
Address
Date of Birth
Gender
Male
Female
Other
1. Health & Medical Information
Do you have any diagnosed medical conditions? (Check all that apply)
Diabetes
Hypertension
High Cholesterol
Obesity
Thyroid Disorders
Kidney Disease
PCOS
Heart Disease
Digestive Issues
Food Allergies
Other Conditions
Current Weight (kg)
Height (cm)
Weight Goal
Lose Weight
Maintain Weight
Gain Muscle
Are you taking any medications or supplements?
Yes
No
Do you experience any of the following? (Check all that apply)
Frequent bloating
Constipation
Diarrhea
Low energy
Sugar cravings
Emotional eating
Frequent headaches
Poor sleep quality
4. Medical & Surgical History
Tell us your surgical history
2. Dietary Habits & Food Preferences
How many meals do you eat per day?
1
2
3
4+
Do you skip meals?
Yes
No
Protein Sources (Check what you consume regularly)
Chicken
Turkey
Fish
Eggs
Beans
Lentils
Tofu
Red Meat
Dairy
Nuts & Seeds
Carbohydrate Sources
Brown Rice
White Rice
Yam
Plantains
Fufu
Bread
Pasta
Quinoa
Millet
Sorghum
Whole Wheat
Foods You Avoid (Due to allergies, culture, or preference)
How often do you consume sugary drinks?
Never
Occasionally
Daily
Do you eat vegetables daily?
Yes
No
Do you eat fruits daily?
Yes
No
How often do you eat out?
Rarely
1-2x per week
3+ times per week
Favorite Meals
Least Favorite Foods
3. Hydration & Lifestyle
Daily Water Intake
<1L
1-2L
2.5L+
Do you consume caffeine?
Yes
No
Do you drink alcohol?
Yes
No
Do you smoke?
Yes
No
Exercise Routine (Check all that apply)
None
Walking
Jogging
Weight Training
Yoga
Other
Sleep Quality
Poor (<5 hrs)
Average (6-7 hrs)
Good (7+ hrs)
Stress Levels
Low
Moderate
High
4. Wellness Goals & Preferences
What are your top 3 health goals? (Check up to 3)
Weight Loss
Muscle Gain
More Energy
Better Digestion
Blood Sugar Control
Heart Health
Improved Sleep
Detox/Cleansing
Preferred Nutrition Plan Style
Low-Carb/Keto
High-Protein
Plant-Based/Vegan
Balanced Diet
Traditional Ghanaian Diet with Healthy Adjustments
Have you followed a diet or meal plan before?
Yes
No
5. Additional Notes & Special Requests
Do you have any specific health concerns or questions?
How can we best support you in reaching your goals?
Next Steps:
Personalized Nutrition Plan will be created based on this intake.
Follow-up in 2-4 weeks to assess progress and make adjustments.
Join our Wellness Community for motivation, meal plans & support!
Submit Assessment