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Lifestyle Nutrition and Wellness, LLC
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MEDICAL & NUTRITION HISTORY
Name
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Your answer
Home Address
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Your answer
E-Mail
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Your answer
Birthdate
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Your answer
Age
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Your answer
Best Phone Number
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Your answer
How did you hear about Lifestyle Nutrition and Wellness?
Your answer
Would you like to know if your health insurance would cover your visit with a Registered Dietitian?
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Yes
No
Maybe
If yes, who is your health insurance carrier?
Your answer
What is the name of the subscriber:
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Subscriber ID:
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What goals would you like to accomplish?
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Improve overall health
Lose weight
Improve cholesterol levels
Improve blood pressure
Improve gut health
Improve physical fitness
Improve blood glucose
Manage stress better
Other:
Required
I am interested in the following topics.
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Meal Planning
Food Label Reading
Mediterranean Way of Eating
Plant-based Eating / Vegan
Vegetarian Eating
Fiber and Cholesterol
Improve Gut Health
Inflammation Reduction
Managing Emotional Eating
Stress Management Techniques
Exercise and Fitness
Sports Performance
Goal Setting
Living Longer
Motivation and Weight Loss
Other:
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Height (feet & inches, please)
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Weight (pounds & ounces, please)
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Your answer
Describe any recent change(s) in your weight.
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Your answer
Please list any medications you take and why you the medication.
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Your answer
How many hours of sleep do you get on average each night?
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Your answer
Is sleeping a problem?
Yes
No
Sometimes
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Please list any supplements you take & how often you take them.
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Your answer
Please list any allergies.
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Your answer
Check any of the following that pertain to you NOW or in the PAST.
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None
Overweight
Obesity
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease
Short of Breath
Swollen ankles or lower legs
Kidney Disease
Thyroid Problems
Cancer
Rheumatoid Arthritis
GERD
Irritable Bowel
Eating Disorder (binge/purge)
Depression
Other:
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Please list any surgeries you've had.
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None
Other:
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For Women (Date of your last menstrual period)
Your answer
For Women are you pregnant or do you plan on getting pregnant in the next 6 months?
Yes
No
I'm not sure
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Do you drink alcohol? If yes, how often?
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Your answer
Do you use tobacco? If yes, what kind and how often?
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Your answer
Are you an emotional eater? If yes, please describe.
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Your answer
How often do you exercise? Please describe your current exercise routine.
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Your answer
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