Pregnancy Plan Checkout - Nutrition Nanny

Name *

First

Last

Email *

Age *

Height *

Weight entering pregnancy *

What week of pregnancy are you in? *

Is this your first pregnancy? *

PREGNANCY HISTORY: How many children do you have? *

Please list their ages: *

Did you experience any of the following in your prior pregnancies?  Please check all that apply: *

Morning sickness (ending near or in second trimester)
Hyperemesis Gravidarum (severe morning sickness throughout all trimesters)
Hyperphagia (extreme cravings & appetite)
Gestational Diabetes

If other, please describe: *

Are you CURRENTLY experiencing: *

Morning sickness
Aversions

If yes to above, please describe morning sickness duration, and any aversive foods & beverages *

If applicable, which would best describe your average weight gain in prior pregnancies? *

Gained below goal range
Gained within goal range
Exceeded goal range

By How Much? *

WORK & HOME ENVIRONMENT: Do you work outside the home?

If YES, what level of activity best describes your work environment? *

Do you share household responsibilities with a significant other? *

Who does most of the cooking? *

Do you have regularly scheduled family dinners? *

If yes, how many nights a week? *

If you have other children, do they follow a snack schedule? *

YOUR NUTRITION: Please list any food allergies, or none: *

Please list any food sensitivities/intolerances, or none: *

Which best describes your eating habits (before pregnancy)? *

I eat a healthy diet primarily and keep to three meals daily.
I consume a lot of fast food on the run and eat when I am hungry.
I keep to a good meal schedule, but tend to give into sweet or salty cravings.
I eat smaller healthy meals about 4-5 times each day.

DAILY/WEEKLY SNAPSHOT (BEFORE PREGNANCY): How many servings of vegetables do you eat Daily?/Weekly? *

How many servings of fruits do you eat Daily?/Weekly? *

How many fast/convenient meals do you eat Daily?/Weekly? *

What is your main source of daily hydration? # oz. daily? *

How many ounces of sweetened beverages do you drink daily? *

How many sweet snacks do you eat Daily?/Weekly? *

How many salty/savory snacks do you eat Daily?/Weekly? *

CURRENT MEAL/SNACK PATTERNS: When I eat breakfast, it consists of: (or none.) *

When I snack mid-morning, it consists of: (or none.) *

When I eat lunch, it consists of: (or none.) *

When I eat an afternoon snack, it consists of: (or none.) *

When I eat dinner, it consists of: (or none.) *

When I eat an evening snack, it consists of: (or none.) *

Do you have any specific concerns, issues, or problems that you feel a more customized Nutrition Nanny® Action Plan can help you with? Please explain in 240 words or less: *

Next: Sign up for your 15 minute introductory call!

Next: Complete Your Lifestyle & Diet Profile

Next: Sign up for your 15 minute introductory call!

Next: Complete Your Lifestyle & Diet Profile

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