Nutrition Assessment Form

Personal Health History

Food intolerances

Digestive issues


Frequent colds/flu/coughs/runny nose/stuffy

Problems sleeping/insomnia

Heart disorder/heart attack/stroke/angina

High cholesterol

Osteoporosis/Low bone density

High blood pressure


Hypoglycemia (low blood sugar)

High blood sugar


Thyroid problems

Low iron/anemia

Depression/anxiety/psychiatric care

Frequent headaches/migraines



Currently pregnant/breastfeeding

Anorexia/bulimia/binge eating

Joint/back/tendon/muscular pain or injury

Lung disease/asthma

Lifestyle Factors

Do you exercise?


Do you take time to relax each day?

How is your energy throughout the day?

What is your mood like most days?

Do you experience any cravings throughout the day?

Do you smoke?

Are you exposed to 2nd hand smoke?

Do you use medicinal or recreational cannabis?


Please list the name and dosage of any medications you are currently taking as well as the reason for taking it.

Name of Medication
Dosage & Reason For Taking

Vitamins, Minerals, Supplements & Herbs

Please list the name and dosage of any supplements you are currently taking as well as the reason for taking it.

Name Of Supplement
Dosage & Reason For Taking
Family Medical History
List the family member and details

Food/Environmental allergies

Intestinal disease

Heart disorder/heart attack/stroke

High cholesterol

High blood pressure


Diabetes/High blood sugar

Hypoglycemia (low blood sugar)





Other medical issues

I understand and acknowledge that the nutrition services provided by The Kettlebell Club are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. If you are currently taking any pharmaceutical prescription drugs, it is advised that you consult your Doctor before combining them with nutritional supplements.