Telephone:
Name (required):
Date:
Date of Birth:
Age:
Gender you identify with:
Height:
Current Weight:
Occupation:
Hours of work per week:
Relationship Status:
Number of Children:
Address:
City, State, ZIP:
Cell:
Home:
Work:
Email Address (required):
Emergency Contact:
Personal Physician:
How did you hear about Physical Equilibrium?
If you were referred by a physician, please provide physician name, if different from above:
Date referred:
Please list any current medications, including vitamins, supplements and non-prescription drugs:
Is this your first time seeing a Registered Dietitian?
[radio* first-time-dietitian use_label_element "Yes" "No"]
What is the main purpose of your visit?
Please list any illnesses or conditions (for example, diabetes, high blood pressure, cancer, heart disease):
Please list family history of any illnesses or conditions (for example, diabetes, high blood pressure, cancer, heart disease):
Have you ever had surgery or been hospitalized? If yes, please explain:
Have you recently had a nutritionally significant lab (for example, high cholesterol, anemia)?:
Medicine:
Dosage/frequency:
Are you pregnant or is it likely that you could be pregnant at this time?
[radio* pregnant use_label_element "Yes" "No"]
What is the level of stress in your life?
HighModerateLow
Do you smoke or have you ever smoked? If yes, what age did you start?
How many cigarettes do you smoke per day?
Do you drink alcohol? If yes, how many drinks per week?
Do you sleep well? How many hours? Do you wake up at night?
Do you have a history of disordered eating? If yes, please explain:
Do you exercise regularly?
YesNo
If yes, please fill in the chart below:
Type(s) of exercise:
Frequency (days per week):
Duration (minutes):
Intensity (low, moderate, high):
LowModerateHigh
Have you had any recent significant weight gain or loss?
What was your weight 6 months ago:
One year ago:
Do you currently consider yourself to be at your ideal weight?
If not, what is your ideal weight?
What made you choose this number?
Generally speaking, how do you feel about your weight (unhappy/frustrated, slightly dissatisfied, ambivalent, satisfied etc):
Are you allergic to any foods?
If yes, please list the food items as well as your allergic response:
Food:
Allergic Response:
Do you have any dietary restrictions or intolerances? (i.e. Vegetarian/vegan, gluten free, lactose intolerance, etc.)
What are your food dislikes (i.e. what will you absolutely not eat?)
What do you hope to achieve during your visit with a dietitian?
Please list one short-term goal and one long-term goal:
Short-term:
Long-term:
Please share any other questions or concerns that you would like to address during your visit:
I have answered the Health History Questionnaire questions accurately and completely. I understand that my medical history is a very important factor in this nutrition-counseling program.
First & last name (print):
Signature:
