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Please fill out the following form completely to be contacted for an appointment. Thank you.

What prompted you to reach out to me for help?

Have you even seen a dietitian before?

Yes

No

If I could change three things about my health and nutritional habits, they would be...

What are your biggest challenges or obstacles with making these changes?

At this time, are you currently using MyFitnessPal or any other app to log your food?

Yes

No

On a scale of 1 to 10, how committed are you to your personal nutrition goals?

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Thank you.

Sarah Stapelmann MS, RDN, LD, CLT

©2017 by Sarah Stapelmann Nutrition. Website content is provided for educational purposes only and is not intended to be diagnostic.