Client Name:
Date:
Email:
Phone:
DOB:
Age:
Height:
Weight:
Gender: MaleFemale
Occupation:
Marital Status:
With whom do you live?:
Do you have pets?(if yes, list):
Primary reasonor reasonsfor visit:
Current satisfaction with weight:
Current satisfaction with health:
Favorite foods(list):
Level of eating enjoyment:
Level of cooking enjoyment & frequency:
Currentand previous diets(list, if any):
Please list any allergies to food, drugs, or environment:
History of Medical Conditions (list):
History of disordered eating(if yes, when and how long):
History of use of antibiotics, PPIs, or pain killers(if yes, when and how long):
History of other medications (Rx, OTC, and supplements):
Indicate if there have been any of the following diseases in you, your parents, grandparents, brothers, sisters or children. Indicate the number of relatives who have the disease.
Cancer:
Diabetes:
Epilepsy:
Heart Disease:
High Blood Pressure:
Stroke:
Anemia:
Kidney Disease:
Mental Illness:
Allergies:
Asthma:
Arthritis:
Alzheimer’s:
Frequency and type of exercise:
Hobbies or otherinterests:
Average hrs of sleep per week:
Quality of sleep:
Stress Level (0-10):
Major causes of stress:
Self-care practices:
# of alcoholic beverages per week:
# of caffeinated beverages per week:
Tobacco use(if yes, how often):
Anything else you’d like me to know?:
Please list all foods and portion sizes consumed within the past 24 hours. Please include as much detail as possible quantities, brand, restaurant, fast-food, home cooked, condiments, and sweeteners if possible.
Breakfast:
Snack:
Lunch:
Dinner:
Dessert:
Beverages:
Movement/exercise:
Mood/symptoms:
Other information:
