Client Nutrition Assessment Form

Let's get to know you

Answer step by step. At the end you'll get the completed assessment form as a PDF to send to on WhatsApp.

Your data stays on your device. Nothing is uploaded to any server or database. Your answers are saved only in this browser, so you can fill the 3-day food recall over three days and come back to this page each day.

Personal Information

1. Full name *

2. Age *

3. Gender *

Female Male

4. Height *

5. Weight (kg) *

6. Waist circumference

7. Hip circumference

Your BMI

Enter height & weight

1518.5253040

BMI is a screening tool, not a diagnosis. Your dietitian will read it alongside your other details.

Medical & Health History

8. Current medical conditions (if any)

9. Any food allergies or intolerances

10. Current medications

10. Current supplements

11. Stress / anxiety level *

LowMostly calm and in control

ModerateSome pressure, usually manageable

HighOften overwhelmed or anxious

Lifestyle

12. Walk / physical activity (type)

Duration & frequency

13. Sleep pattern (hours/day)

Sleep notes (optional)

Review & get your PDF