Dr. Marwa Nutrition Assessment

Welcome to Your Nutrition Journey

This comprehensive assessment will help us understand your medical history, lifestyle, and goals to create a highly personalized and effective clinical nutrition plan. Please fill it out as accurately as possible.

Your progress is saved automatically. You can safely close this page and return later.

SECTION 1: Personal Information

Full Name

Age

Gender

Male Female

Phone Number (WhatsApp)

Email Address

SECTION 2: Female Health

Is your menstrual cycle regular?

Have you been diagnosed with Polycystic Ovary Syndrome (PCOS)?

Are you currently pregnant?

Are you currently breastfeeding?

SECTION 3: Body Measurements, Goals & Expectations

Current Weight (kg)

Height (cm)

BMI Summary

Goal Weight (kg)

Waist Circumference (cm)

Hip Circumference (cm)

Primary Goal

SECTION 4: Medical History & Health Status

Are you currently taking any medications?

Yes No

Are you currently taking any supplements?

Yes No

Do you have any family medical history that we should be aware of?

Yes No

How often do you experience the following digestive symptoms?

Symptom	Never	Rarely	Sometimes	Often	Always
Bloating
Gas
Constipation
Diarrhea
Acid Reflux
Stomach Pain

Do you have recent blood work results?

Yes No

Blood Work Upload

Upload your recent blood work results (PDF, JPG, PNG)

SECTION 5: Lifestyle & Stress Assessment

How would you describe your daily activity level?

How many hours do you sleep on average per night?

How would you rate your sleep quality?

Do you currently exercise?

Yes No

EXERCISE HABITS

What type(s) of exercise do you currently perform?

Strength Training / Weightlifting Cardio CrossFit Yoga / Pilates Swimming

How many days per week do you exercise?

How long is a typical workout session?

SECTION 6: Nutrition & Eating Habits

Which of the following diets or nutrition approaches have you tried before?

Calorie Counting Keto Low Carb Intermittent Fasting

Which diet or nutrition approach worked best for you?

Why did you stop following that approach?

How many meals do you typically eat per day?

How many snacks do you typically eat per day?

How much water do you drink per day?

How often do you eat at restaurants or dine out?

SECTION 7: Food Preferences, Appetite & Eating Behavior

Do you have any food allergies?

What foods do you enjoy eating most?

Are there any foods you dislike?

Which dietary style best describes your current eating pattern?

Do you experience food cravings?

How often do you eat in response to emotions rather than physical hunger?

Do you experience night eating or frequently eat late at night?

Do you feel like you lose control around certain foods?

Yes No

SECTION 8: Eating Environment & 24-Hour Recall

What did you eat and drink yesterday?

SECTION 9: Adherence, Progress Tracking & Final Notes

What usually causes you to stop following a nutrition plan?

Files & Photos

Please upload your progress photos.

Front

Side

Back

Please upload your most recent InBody scan.

Please upload any relevant medical reports.

Is there anything else you would like your nutritionist to know?

Review Your Assessment

Please review your answers before submitting. You can go back to edit any section.