SLIDING SCALE NUTRITION INTROSPECTION QUESTIONNAIRE 

The following is a list of questions I have my clients answer before our first session. If you don’t understand a question, please make note of it so I can rephrase the question for you and future clients. If you don’t want to answer a particular question, please leave it blank. I recognize that these questions will not all be easy or quick to answer. However, the more time and thought you put into the answers the more success we will have in helping you achieve your goals! 

GOAL(S)

1. What goal(s) do you hope I can help you achieve?

MOTIVATION TO CHANGE

I like for you to articulate for yourself and for me what motivates you to want to make diet and lifestyle changes.

2. What is motivating you to seek guidance and make changes?

3. How strong would you say this motivation is on a scale of 1-10?

(10 is so strong you’ll make every change you need to make immediately. 1 being strong enough to look for help but not actually make any changes)

4. Are you willing to make some changes in your diet and lifestyle to achieve the goals you set?

5. What kind of changes are you willing to make?

6. If these changes feel like sacrifices are you willing to make them (or some) to achieve your goal(s)?

CURRENT DIET/LIFESTYLE/HEALTH HABITS 

7. What are the foods you currently eat most often? (Pasta? Rice? Vegetables? Meats? Eggs? Cereal? etc.)

8. Do you read the ingredient label on packaged foods? 

9. Do you read or pay attention to the nutrition label?

10. How much time do you spend preparing food in a day or week (including preparing, cooking and cleaning)?

11. How much time are you willing to spend preparing food in a given day or week?

12. Is money a factor in your food shopping?

SOCIAL SUPPORT

13. Do you have any friends or family who are making or have made similar changes who could support you while you make changes?

14. Do you have other friends or family who would be willing to support you while you make changes?

OBSTACLES

15.What obstacles/barriers do you predict you will encounter while trying to reach your goal(s)?

16. Are you the kind of person who finds lots of reasons for not making changes you “know you should make”?

17. Are you willing to address those reasons if they seem to be preventing you from making the change you want to make?