Home
Services
Referring Providers
Individuals
Contact us
Forms
Menu
Home
Services
Referring Providers
Individuals
Contact us
Forms
PAY NOW
Medical Nutrition Therapy
Patient Intake Form
General Information
Date
*
Name
*
Sex
*
Male
Female
Race
Age
*
DOB
*
Home
Work
Cell
Primary Language
*
Occupation
Who lives in your home?
Possible Barriers of Learning (check all that apply)
Visual
Auditory
Literacy
Language
Cultural/religious
Other (please describe)
Medical History
Height
Current Weight
Your goal weight
Past Medical History
Past Surgery History
Allergies: Food
Medication
Labs: Date
LDL
HDL
Triglycerides
Total Cholesterol
A1C
Current Medication(s) Name and dosage (prescribed or over-the-counter)
Nutrition
Do you follow a specific diet?
Yes
No
Have you ever seen a dietitian?
Yes
No
If yes, explain?
If yes, when was the last time?
How often do you eat out?
Who cooks at home?
Grocery shop?
Exercise
Type of exercise
How often?
Duration?
Any restrictions?
Yes
No
If yes, explain
Lifestyle
What kind of work do you do?
What hours do you work?
What time do you usually get up in the morning?
Go to bed?
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
If yes, how much/how long?
If yes, number of drinks per week?
Do you have any cultural/religious practices that impact your diet/exercise?
Yes
No
If yes, please explain
How would you describe your general health?
Good
Fair
Poor
How would you describe your general health?
In the space below, please write down the foods consumed from the previous day to indicate a typical day’s food/beverage intake
This box is for spam protection - <strong>please leave it blank</strong>: