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Katy@UpliftNutritionist.com

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Intake Form - Uplift Nutrition

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):

Medical History

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):

Family History

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:

Lifestyle

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?:

24 Hr Diet Recall

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:

Snack:

Dinner:

Dessert:

Beverages:

Movement/exercise:

Mood/symptoms:

Other information: