Introductory Assessment

Client Assessment Form

Thank you for dedicating time to fill out this questionnaire. Your responses will guide our discussion, allowing us to delve deeper into your needs and determine the support required to help you achieve your goals.

Basic Info

Part A: Areas Of Interest

Please Tick The Areas Of Women’s Nutrition That Are Of Interest To You:Eating For Physical And Mental Well-BeingHealthy, Sustainable Weight LossRestoring Or Regulating Menstrual CyclesBoosting FertilityRecovering From Hypothalamic AmenorrhoeaNavigating & Managing PCOSNutrition During (Peri)MenopauseAddressing Digestive IssuesImproving Your Relationship With Food

Part B: Are You An Emotional Eater?

1. Do you eat more than you would like to when you have negative feelings, such as anxiety, depression, anger, or loneliness?

2. Do you have trouble controlling your eating when you have positive feelings – do you celebrate feeling good by eating?

3. When you have unpleasant interactions with others in your life, or after a difficult day at work, do you eat more than you would like?

Part C: Could It Be Binge Eating?

1. During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)?

Part D: Are You Struggling with Body Image and Food Control?

Please tick the ones that seem relatable to you.I have tried following definite rules regarding my eating (for example, a calorie limit) in order to influence my weight.I have a definite desire to have an empty stomach with the aim of influencing my shape or weight.I am constantly thinking about my body image or food and it’s difficult to concentrate on other things (e.g. working, following a conversation, or reading).I worry a lot about losing control over eating or gaining weight.My body shape/ weight has influenced how I think about (judge) myself as a person.

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