How did you hear about Nutrition Performance?
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- Camron Alexander
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1 Please complete and read the following information before your first appointment: Name : Date : Birthdate : Phone How did you hear about Nutrition Performance? Cell. Home. Sports and activities that you practice regularly : Address Do you have insurances coverying health services / paramedical? Yes No If so, which one? Dietitian / Nutritionist Naturopathe, Naturotherapist CANCELLATION POLICY What is your insurance company? Amount covered annually : We want to offer a high quality service and a variety of availabilities to people who wish to consult us. We also receive many consultation requests every day. Unfortunately, some people neglect to show up at their scheduled appointments and do not notify us. This is why we now have a cancellation policy of appointments: 1. If you wish to cancel your appointment, you must provide at least 24 hours notice before the scheduled date and time. 2. Appointments canceled with less than 24 hours notice or «no show» will be charged 50% of the amount of the service provided. You can cancel your appointment with the GOrendezvous online application, by or by phone. Understand that this deadline gives us the opportunity to offer this time slot to another person. We also reserve the right to refuse access to an appointment if the situation should be repeated three or more times. I read and understand this policy and agree to pay the cancellation fee if I provide less than 24 hours notice of cancellation of an appointment. Signature
2 CONSULTATION FEES Individual Evaluation 90 minutes 120 $ Follow-up 60 minutes 90$ Follow-up 30 minutes 60$ Body composition 50$ Packages We offer different evaluation and follow-up packages ranging from 180$ to 460$. Visit our website prior to your first appointment to learn more about our services Follow-up packages 4 x 30 minutes 240$ 3 x 60 minutes 270$ Payment methods : Credit cards Cash Cheque Bank transfer (done on-site) INSTRUCTIONS FOR COMPLETING THE FOOD DIARY : Make sure that your food diary reflects your regular eating and diet. List all foods and liquids consumed (meals, snacks, hydration during the day) Be as specific as possible. Enter the quantity, measure your servings, that note of the brand, write down cooking methods and precise type of foods (eg milk 2% fat, chicken.: Breast or leg, skin, etc.) If you eat outside, specify the restaurant and estimate serving sizes with your hands, palm, fist, etc. If you take supplements, indicate brands and dosage you are taking.
3 Tell us about your goals. Why would you like to meet a Dietitian-Nutritionist?: Do you have any weight goals? How would you describe your silhouette? I would like to lose weight (fat) I feel too skinny (>10lbs) I would like to gain weight (muscle mass) I feel somewhat skinny (5~10lbs) I want to keep the same weight I feel great the way I am I am not doing anything about my weight I feel a little bit overweight (5~10lbs) I feel overweight (10~20lbs) I feel very overweight (>20lbs) In the past 3 months, have you ever had the following symptoms : I am more tired then usual I have a hard time recovering from my trainings I feel dizzy during the day and/or during training. I have gastro-intestinal problems (more then usual) I get constipation issues (more then usual) I have less motivation to cook / do grocery shopping I lose control over food (eat large amounts in short time) I feel guilty after eating certain types of foods I think a lot about food For women : I have menstrual disturbances Have you ever met a Dietitian / Nutritionist in the past or got any nutrition recommendations by someone else? If so, explain : Do you currently follow a particular diet? If so, explain : What is your current weight? Is this your usual weight and how long have you been at this weight? Do you have allergies or intolerances? Do you sleep well? On average, how many hours a night do you sleep? Write down any medication, supplements or natural health products that you are currently taking :
4 Day 1 : Pick a training day Make sure this reflects your usual eating habits. (use extra sheets at the end, if needed)
5 Day 2 : Pick a training day Make sure this reflects your usual eating habits. (use extra sheets at the end, if needed)
6 Day 3 : Pick a rest day Make sure this reflects your usual eating habits. (use extra sheets at the end, if needed)
7 Extra sheets
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