PlantBased Nutrition Client Assessment Questionnaire

Why a Structured Questionnaire Matters

Transitioning to a plantbased diet offers many health benefits, but each client arrives with a unique history, goals, and potential challenges. A welldesigned questionnaire captures the essential data you need to:

• Identify nutritional gaps and potential deficiencies.
• Understand medical conditions that affect dietary choices.
• Set realistic, personalized goals.
• Track progress over time.

Core Sections of the Questionnaire

1. Personal Information

Collect basic identification data to keep records organized and to personalize communication.

• Name
• Date of birth
• Gender (optional)
• Email and phone number
• Preferred method of contact

2. Lifestyle & Activity Level

Understanding daily activity helps estimate caloric needs.

• Occupation (sedentary, moderately active, active)
• Typical weekly exercise routine (type, frequency, duration)
• Sleep patterns and stress levels

3. Health History

Identify conditions that influence nutrient requirements or food choices.

• Current medical diagnoses (e.g., diabetes, hypertension, thyroid disorders)
• Past surgeries or gastrointestinal issues
• Medications and supplements
• Allergies and food intolerances

4. Current Dietary Habits

Map out what the client is already eating to pinpoint areas for change.

• Typical daily meals and snacks (including portion sizes)
• Frequency of animalderived foods (if any)
• Use of processed foods, added sugars, and sodium
• Beverage intake (water, coffee, tea, alcohol, sugary drinks)

5. Motivation & Goals

Clarify why the client wants to adopt a plantbased diet and what success looks like for them.

• Primary motivation (health, ethics, environment, performance)
• Shortterm goals (e.g., Add two plantbased meals per week)
• Longterm goals (e.g., Achieve vitamin B12 sufficiency within 3 months)

6. Nutrient Awareness

Assess knowledge that may affect compliance.

• Familiarity with protein sources, omega3 fats, iron, calcium, and vitamin B12.
• Understanding of fortified foods and supplementation.

7. Support System & Barriers

Identify external factors that will help or hinder progress.

• Household eating patterns (does anyone cook for them?)
• Access to grocery stores, farmers markets, or specialty shops
• Time constraints for meal preparation
• Potential cultural or social obstacles

Sample Questionnaire (HTML Form)

Below is a readytouse HTML form. You can copy it into your website and customize fields as needed.

*All data collected should be stored securely and in compliance with local privacy regulations.

How to Use the Questionnaire Results

1. Review baseline data: Look for red flags such as a history of anemia, low B12 intake, or high cardiovascular risk.
2. Calculate macro and micronutrient targets: Use the clients age, sex, weight, activity level, and health goals to set personalized protein, iron, calcium, and omega3 recommendations.
3. Identify education needs: If knowledge scores are low, schedule a focused teaching session on those nutrients.
4. Develop an action plan: Break goals into weekly tasks (e.g., Add one legume serving each day). Include grocery lists, recipe ideas, and supplement suggestions when appropriate.
5. Set followup intervals: Readminister the questionnaire every 46 weeks to monitor changes and adjust the plan.