Consent FormIntake Form General Information Name * First Name Last Name Age DOB * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Phone (###) ### #### Email * Occupation * Relationship Status * Single Married Divorced In a relationship Do you have children * Yes No Number of children Medical History Existing Conditions Check all that apply Heart Disease Hypertension High Cholesterol Diabetes Cancer IBS/IBD Eating Disorder Anxiety Depression When was your last physical or blood work? Allergies List all the apply Foods Medications Supplements Environmental GI Issues Select all that apply Diarrhea Bloating Gas Constipation Upset stomach Heartburn Do you take anything to help your bowel movements? If yes, list the name and frequency taken Medications, Vitamins, and Supplements Name, Dose, Frequency, Reason for Use Start new line for each item Weight History Height Current Weight Usual Weight Range Have you lost or gained weight recently? Yes No If yes, please explain Lifestyle Do you exercise? Yes No If yes, please explain Activity Type, Number of Days per Week, Duration (minutes) Start new line for each activity Do you smoke? Yes No If yes, how often? Nutrition History Have you ever met with a dietitian or nutritionist? Yes No If yes, please list the reason for the visit Do you follow a special diet or have diet restrictions or limitations due to health, religion, or other? Do you avoid any particular foods? Who grocery shops in your household? Who prepares or cooks the most meals? How many meals do you eat out per week? Favorite foods? Least favorite foods? What kind of proteins do you consume? Select all that apply Animal meat Soy based Beans Dairy Eggs Nuts & seeds What do you drink? Beverage, Amount per Day Start new line for each beverage (water, coffee, tea, soda, juices, energy drinks, alcohol, etc.) If you drink coffee or tea, do you add anything to it? Please list name and amount How many meals do you eat per day? How many snacks do you eat per day? Have you ever been on a diet or specific eating plan? Yes No If yes, please explain Eating habits that I am proud of: Eating habits that are most challenging for me: In your own words, what are your goals for our work together? Eating Habits Select all that apply Love to eat Like to cook Fast eater Emotional eater Late night eater Frequently eat fast foods Rely on convenience foods Time constraints Erratic eater Negative relationship with food Travel frequently 24 Hour Recall Please include as much detail as possible Time, Food or Beverage Item, Approx. Amount Start new line for each option Thank you! Your response has been submitted!
