Born to Eat:

A Return to Instinctive Eating
BORN TO EAT INITIAL SELF ASSESSMENT

Name___________________________________________ Date____________________________________________
Date of Birth_____________________________________ Phone Number___________________________________

Primary goal for using the Online Nutrition Program:
_____________________________________________________________________________________________
_________________________________________________________________________________________________

History of Weight/Body/Eating (start with the earliest memory you have about this, be as detailed as possible): Height___________________________________________ Current Weight (optional)_________________________
Desired Weight (if any)____________________________ Highest Adult Weight_____________________________
When was this?______________________________ Lowest Adult Weight______________________________
When was this?______________________________

Family Weight Issues
Mom's attitude about her body________________________________________________
Dad_____________________________________________________________________________________________
Siblings____________________________________________________________________
Extended Family____________________________________________________________________________________

Previous diet attempts:
________________________________________________________________________________________________

Previous or current exercise patterns:
Duration:_____________________________________________________________________________________
Frequency:___________________________________________________________________________________
Type:___________________________________________________________________________________________

Have you ever used/done the following:

Diet Pills________________________________________________________________________________________
Laxatives__________________________________________________________________________________________
Vomiting_______________________________________________________________________________________
Bingeing____________________________________________________________________________________________
Excessive Exercise____________________________________________________________________________________
Restricting___________________________________________________________________________________________

Are you currently taking any medications?

If so, indicate what they are used for:_____________________________________________________________________
Are you taking any vitamins/supplements?_________________________________________________________

Do you have any of the following:

Dizziness__________________________________________________________________________
Headaches______________________________________________________________________________________
Disorientation_________________________________________________________________________________
Food Cravings______________________________________________________________________________________

Current Eating Pattern (include approximate times and foods):

Breakfast:_________________________________________________________________________________________
Snack:____________________________________________________________________________________________
Lunch:____________________________________________________________________________________________
Snack:____________________________________________________________________________________________
Dinner:____________________________________________________________________________________________
Snack:____________________________________________________________________________________________

What do you feel is the biggest issue you are having with weight/body/eating?
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Please include any other information you feel is important:
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Click Here To Get Started!

You will receive a copy of this self assessment in a email when you enroll for the Instinctive Eating Program.

Listen to your Body, it is Wiser than you Think.
Respect your own unique traits, and develope a healthy relationship with food.

jenpernutrition@yahoo.com