Nutrition Screening Name * First Name Last Name 1. Do you currently or have you ever followed a specific diet (WW, Keto, Intermittent Fasting etc)? * Yes No 2. Do you feel like you have a big appetite compared to others? * Yes No 3. Do you ever feel uncomfortably full after eating or drinking sometimes? * Yes No 4. Have you ever felt guilt, shame or discomfort after "over-eating"? * Yes No 5. Does your weight fluctuate 5lbs. in either direction, up or down? * Yes No 6. Have you ever made yourself vomit after eating? * Yes No 7. Would you continue your current exercise regimen if it could not change your body weight or shape? * Yes No 8. Do you feel like you put things off because of the way you look? * Yes No 9. Is it hard for you to tell if you are hungry or full? * Yes No 10. How does the way you look or how you eat affect your social life? * Thank you! Please contact info@fitinhealth.com with any concerns.
