Name Date of Birth

Gender Male Female Age

Reason(s) for Consultation (in order of importance)

Referring Physician Name and Phone number:

Please indicate whether you or a family member have or have had any of the following conditions:

Disease/Condition / Self / Family / Relationship / Treatment
Asthma
Cancer
Celiac Disease
Cardiovascular Disease
Crohn’s Disease
Diabetes
Depression
Eating Disorders
Eczema
Food Allergies
Food Intolerances
High Blood Pressure
High Cholesterol
Heart Attack
Hypogylcemia
Irritable Bowel Syndrome
Kidney Disorder
Lactose Intolerance
Migraine
Osteoporosis
Sleep Apnea
Thyroid Disorder
Other
Other

Please list any pertinent lab values (or bring a copy of labs with you to appointment)

Please list all Medications and/or supplements (Prescribed, Over-the-Counter, Vitamins, Herbs)

Medication/Supplement / Dosage / Times per Day

Do you drink alcohol? yes no Number of drinks per week

Do you smoke? yes no

Do you engage in an exercise program? yes no

If yes, what type and how often?

Do you have any physical conditions that limit your ability to exercise? yes no

What type of hobbies do you like to do?

Have you every worked with a dietitian/ nutritionist? yes no

Weight History

Height Current Weight Highest Weight

Do you consider yourself Underweight Overweight No Weight Issues

If under or overweight, what did you weigh 6 months ago?

If under or overweight, what do you feel your ideal weight is?

Have you had your energy expenditure measured? yes no

If yes, when?

DIET HISTORY

Have you ever been advised by your physician to follow a special diet? Yes No

If yes, please elaborate:

How many time per week do you eat the following meals either in a restaurant or as take-outs?

Breakfast Lunch Dinner

What restaurants do you typically go to?

On an average day, how many times do you eat from the following groups?

FOOD / BEVERAGES
Fruit / JUice
Vegetables / soda
Bread/Cereal/RICE/Pasta / diet soda
BEANS/LEGUMES / Sweetened beverages
nuts/seeds / alcoholic beverages
Dairy (milk, yogurt, cheese) / water
BEEF/PORK / coffee/tea
Poultry
fish
chips/pretzles/crackers
candy/chocolate/Cookies
Butter/Dressing/Sour cream
OTHER

24 hour recall

Please list all the food and beverages consumed for the last 24 hour

FOOD/DRINK / AMOUNT / LOCATION CONSUMED

How typical was this day?

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