Getting Started

• Contact Jennifer via email at jkoslo@koslosnutritionsolutions.com to discuss the option that is right for you or call her at  602-363-4442 .
• Complete and submit Koslo’s Nutrition Solutions nutrition history questionnaire, below.
• Submit your deposit of $25.00 via PayPal. Your deposit will be subtracted from the total cost of your consult with the remaining balance due at the time of the consult. You can also submit your payment in full prior to your consult. At this time only cash, check and PayPal are accepted.

Nutrition History Form

For Koslo’s Nutrition Solutions™ to get a better understanding of your nutritional background, we will need some important information about you.

Please fill out the form below:
Please complete and submit this form at least 48 hours before our scheduled meeting.

*Denotes field is required.

Date:
*Phone:
*Your Name:
*Your Email:
Profession:
Marital Status:
*Age:
*Height:
*Weight:
*Desired Weight:
Any family members struggling with weight issues:	YesNo
If the answer to the last question is yes, has this influenced your eating behavior in any way:	YesNo
*How Long Have You Been at Your Current Weight:
*What is your main reason for contacting Koslo's Nutrition Solutions:
*Have you ever worked with a dietitian:	YesNo
Please list any medical diagnoses: (For example: High Blood Pressure, Osteoporosis, etc.)
Please list any current or past medical problems:
Please list any food allergies:
Please list any medications you are taking on a regular basis:
Please list food and /or vitamin supplements you are taking: (Including herbs, sports drinks, etc., please list what kind and how much.):
Is there any history of family medical problems? (For example: Immediate family members have heart disease, high cholesterol, cancer, etc.) If so, please describe:
*Currently, who does the cooking:
*What types of food are prepared:
*Are you a vegetarian:	yesno
*Do you grocery shop:	yesno
*Are you willing to modify your eating habits to reach your goals?:	yesno
*How would you describe your eating habits:
*Do you often skip meals:	yesno
*What do you consider to be your problem areas? (For example: Craving sweets/ Craving Salts/ Binge Eating/ Stress Eating/ Boredom Eating/ Other):
*How often do you eat out:
*What types of restaurants do you visit (Pizza, burgers, Chinese, etc):
*Please list the foods that you like the most:
*Please list some of the foods that you dislike the most:
*How much water do you drink daily:
*How many sodas do you drink daily:
*How many alcoholic drinks do you have daily or weekly:
Are you currently exercising?	yesno
If you are currently exercising, please list amount and types of exercise (including cardiovascular and strength training exercises). Be as specific as possible. List number of days/ week and time spent doing each activity.
What do you drink before, during, and after exercise for fluid replacement:
Describe a typical meal that you would eat before exercising:
Describe a typical meal that you would eat after exercising:
*What are the top three outcomes that you would like to achieve from our session(s):
Please provide any additional information that you feel would assist me in helping you to achieve your goals:
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