Nutrition counseling tracking form

Nutrition consult

Name*

First Last

Phone*

Email*

Truck # (if you want us to contact you via QC messages/reminders)

I will send you a summary and goal list of what we talk about today. How do you prefer me to contact you and send you that info?*

Email
text (google voice)
QualComm
On paper

What type of driver are you*

PSD
TNT
Trainer
solo driver
team driver
in house

Assessment/ Engaging

Engage – build rapport, use open ended questions, uncover values and hopes, offer compassionate value-based reflections maintaining curiosity about your client --Type any relevant info for the ENGAGING section

In general, what are your goals?*

Check all that apply.

Of the above goals, which is most important to you and why? Do you have a past hx of trying to reach similar goals?*

Focusing section-

– bring the conversation to the topic at hand & elicit personal concerns, related symptoms, severity, screening results and wellness indicators

Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries and do you have any medications, either OTC or RX that interact with your lifestyle?*

Yes
No

List conditions/ diagnoses and meds if applicable

Are there any foods you will not eat because of intolerances or allergies? Are there any foods you will not eat because you dislike them?*

What is a typical day of eating look like for you lately?*

What fluids do you drink throughout the day?*

Evoking section

explore reasons for and against change, then help to elaborate on reasons for change, use pros and cons, double sided reflections, readiness rulers and wellness recommendations

Right now, how would you rank your overall eating, nutrition habits on a scale of 1-5?

How would you rank your motivation to change your eating habits on a scale of 1-5

How do you normally cope with your stress?

On average, how many hours per night do you sleep?*

How ready, willing, and able are you to change?

How READY are you to change your behaviors and habits from 1-5?

How WILLING are you to change your behaviors and habits from 1-5?

How ABLE are you to change your behaviors and habits from 1-5?

What would be the biggest benefit to your life if you made a change for your health?

Diagnosis/ Planning section

– collaborate on the ways in which change will happen choosing specific, attainable goals, elicit commitment for health directed behaviors - note specific - statements as to where, when, with whom and how and schedule follow-up

Summary of SMART goal(s) and main benefits of achieving it

Summary of steps to take to reach the goal(s) that span across aforementioned barriers

Nutrition consult tracking form

Nutrition consult

Focusing section-

Evoking section

How ready, willing, and able are you to change?

Diagnosis/ Planning section

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