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(888) 800-0752

The PLC EXAM
CORPORATE HEALTH
- Corporate Health
- Executive Health
About
CONTACT US
- Contact Us
NEWS
- Blog
- Press Releases

Pre-Visit Nutrition Form

Name(Required)

First Last

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

24-Hour Recall

(Please write down everything you ate/drank in the last 24 hours; including time of day, preparation method, portion sizes, location, hunger level, etc.)

Time of Day

Food Information

Additional Information

Hunger Level (1= not hungry, 5=starving)

Current Weight (lbs)

(including all additional weights you have taken since your PLC visit with appropriate dates)

Non-Scale Victories

(ie: clothes, progress pictures, measurements, movement, hydration, sleep, mood)

How are you feeling in your clothes/how are your clothes fitting?

Have you met your goals since we last met? If you did not see the results you had hoped for, why do you think that is?

What would you like to do better?

Overall hunger (1= not hungry, 5=starving)

1

2

3

4

5

Energy levels (1= exhausted, 5=very energized)

1

2

3

4

5

Sleep (1=not good, 5=great)

1

2

3

4

5

How much water have you been drinking on average?

If you have been exercising, what have you been doing?

If applicable, when was your last menstrual cycle?

MM slash DD slash YYYY

Have you been having regular bowel movements?

How has your mood been since we last met?

What questions do you have for me/what do you need from me to help you be successful?

What's ONE nutrition/food related goal you'd like to set for this week?

What's ONE non-nutrition/food related goal (personal, family) you'd like to set this week?

Anything else you'd like me to know

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Phone

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