The Cultural Dietitian

Intake Questionnaire

Please complete your Intake Questionnaire prior to our 1st consultation. I encourage you to be as honest and thorough as possible as the responses you provide here will serve as a benchmark for your progress moving forward.

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Full Name

Nutrition consultation with Amber is a completely customized approach to eating. Rather than focusing on a prescriptive diet/program, we focus on exploring what works for you and your body and creating a life-giving relationship with food, free from guilt and shame, that builds a sustainable roadmap to your goals. Are you willing to explore this approach that often requires unlearning things you've heard about food and nutrition previously?

* Required

What specifically do you want to achieve in the next 6 months?

When you see yourself reaching your goal, what does that look/feel like? Describe what success means to you. Is it a number/feeling/quality of life?

How will your life be different when you achieve these goals? Who else will be positively impacted when you achieve your goals?

How would you like to measure progress toward your goal? If you’re unsure, that’s okay! We can discuss this together.

On a scale of 1-10, how is your energy?

When it comes to your relationship with food, what is your biggest strength?

When it comes to your relationship with food, what is your biggest challenge?

Are there any foods you can't live without?

What does a TYPICAL day of eating look like for you?

Do you have any dietary restrictions (allergies, sensitivities, etc.)?

Do you have any digestive issues?

Do you have a diagnosed health condition? If so, please describe, along with listing any prescription medications you take.