FAHP 2001: Client Information Form: Date: _______________

Please complete the following information form with your FAHP4500 client to gain an understanding
of their current nutrition and eating behaviours, habits, and goals.

Name (first name only required): _____________________ Age: _________ Gender: _________

Height (optional): _________ Weight (optional): ________

1. In general, what are your goals? Circle all that apply.

Lose weight / fat Improve physical fitness Build better eating habits

Gain weight Look better Build strength

Maintain weight Feel better Gain muscle

Increase energy Improve athletic performance Improve overall health

Healthy aging Get off or decrease medications

Other (please specify): ______________________________________________________________

2. In your own words, how would like your habits, your health, your eating, and / or your body to
be different?

3. Out of all of the changes you’d like to make, which ones feel most important / urgent?

1. ______________________________________

2. ______________________________________

3. ______________________________________

4. What have you tried in the past (or recently) to change your habits, your health, your eating,
and / or your body?
 5. Which of those changes:
Worked well for you, and why? (Even just a little bit, and even if you might not be doing them
right now.)

Did not work well, and why not?

6. What are some strategies you have considered for changes to your habits, your health, your
eating, and / or your body? (For example: cook more at home or increase water intake)

7. What are some barriers that have prevented you from changing your habits or behaviours?

8. Currently, how would you rate your overall nutrition and eating habits? Please circle.

Horrible 1 2 3 4 5 6 7 8 9 10 Amazing!

Household environment and support network information:

9. Who lives with you? Circle all that apply.

Spouse or partner(s) Child(ren) Other family (e.g. parent, grandparent,sibling,etc.)

Roommate(s) Pets
 10. Who does most of the grocery shopping in your household? Circle all that apply.

Me Roommate(s) Other family

Spouse or partner(s) Child(ren)

11. Who does most of the cooking in your household? Circle all that apply.

Me Roommate(s) Other family

Spouse or partner(s) Child(ren)

12. Who decides on most of the menus / meal types in your household? Circle all that apply.

Me Roommate(s) Other family

Spouse or partner(s) Child(ren)

13. On a scale of 1-10, currently, how much do the people and your environment support your
health, fitness, and / or behavior change? Please circle.

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

14. On a scale of 1-10, how would you rank your health right now? Please circle.

Worst 1 2 3 4 5 6 7 8 9 10 Amazing!

Why?

How are you spending your time?

15. In an average week, how many hours do you spend...

In paid employment? ______ At school or doing school work? _______

Traveling and / or commuting? _____ Volunteering? ______

Taking care of others? (e.g., children, person with a disability, older person) ______

Doing other unpaid work? (e.g., housework, errands) ______

How many total hours per week do you spend doing all these activities? _______
 16. On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
Please circle.

Life is go-go-go 1 2 3 4 5 6 7 8 9 10 Life is calm and relaxed

How is your stress and recovery?

Think about all the activities you’re involved in (e.g., work, school, caregiving, housework, travel).
Then assess as best you can:

17. Given all the demands of your life, what is your typical stress level on an average day? Please
circle.

No stress 1 2 3 4 5 6 7 8 9 10 Very high stress

18. On average, how many hours per night do you sleep? Please circle.

4 or fewer hours 7 hours 10 or more hours

5 hours 8 hours

6 hours 9 hours

19. How do you normally cope with your stress?

How ready, willing, and able are you to change?

20. Currently, on a scale of 1-10: Please circle.

How READY are you to change some of your eating behaviors and habits?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

How WILLING are you to change some of your eating behaviors and habits?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

How ABLE are you to change some of your eating behaviors and habits?

Not at all 1 2 3 4 5 6 7 8 9 10 Completely

Upon completion provide your client with the “Client Food and Eating Habit Journal”. Instruct your
client on how to utilize the journal and have them bring it to you at your next session.

Client Assessment and Information Summary:

This section is to be completed by you after your client meeting and completion of the above
questions. This can be completed in point form.

1. Based on the information provide above from your client, summarize your client’s current
lifestyle.

2. Identify key barriers for your client to making change to their nutrition and eating habits.

3. What are some initial nutrition strategies you may recommend for your client based on their
goals, current lifestyle, and barriers outline above?