4100 Troup Highway
Tyler, Texas 75703
24 Hours A Day
7 Days A Week
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Nutrition Assessment Form
High Blood Pressure?
Diabetic? (I or II)
Do you smoke? How often?
Family History of Cardiovascular Disease, High Blood Pressure, Diabetes? Please explain:
Do you eat breakfast?
How many meals do you eat per day?
Do you drink coffee, sodas, or other carbonated beverages?
What are your weaknesses, obsessions, favorite foods? (healthy and unhealthy)
What are your health goals/expectations? (ex. How much weight loss, areas you’re wanting to tone, areas you’re wanting smaller or more muscular)
How soon are you wanting or needing to see results?
Do you take multi-vitamins or supplements prescribed by a Doctor?
Please list any foods you DISLIKE or ALLERGIES you may have
Protein, meat, shakes, eggs:
Carbs, bread, potatoes, pasta:
Fats, cheese, avocado, almonds, coconut:
What time do you wake up?
What time do you eat breakfast?
What time do you go to bed?
Do you have access to a microwave throughout your day?
Are you able to snack throughout your day?
What time do you exercise?
Liability Terms and Conditions
By accepting these terms, I acknowledge that Ashten Palmer is a Certified Fitness Nutrition Specialist. She cannot cure, prevent, or treat diseases. I acknowledge that Ashten Palmer is not a physician, licensed dietician or nutritionist. I accept the responsibility for any harm, illness, allergic reaction, or death that may result from my participation in this program. I do not hold Ashten Palmer responsible for any lack of results while engaged in this diet program. I understand that it is my responsibility to consult with my physician before starting a nutrition or fitness program with Ashten Palmer.
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