Lifestyle Nutrition and Wellness, LLC

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MEDICAL & NUTRITION HISTORY

Name *

Home Address *

E-Mail *

Birthdate *

Age *

Best Phone Number *

How did you hear about Lifestyle Nutrition and Wellness?

Would you like to know if your health insurance would cover your visit with a Registered Dietitian? *

Yes

Maybe

If yes, who is your health insurance carrier?

What is the name of the subscriber:

Subscriber ID:

What goals would you like to accomplish? *

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. *

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:

Required

Height (feet & inches, please) *

Weight (pounds & ounces, please) *

Describe any recent change(s) in your weight. *

Please list any medications you take and why you the medication. *

How many hours of sleep do you get on average each night? *

Is sleeping a problem?

Yes

Sometimes

Clear selection

Please list any supplements you take & how often you take them. *

Please list any allergies. *

Check any of the following that pertain to you NOW or in the PAST. *

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:

Required

Please list any surgeries you've had. *

None

Other:

Required

For Women (Date of your last menstrual period)

For Women are you pregnant or do you plan on getting pregnant in the next 6 months?

Yes

I'm not sure

Clear selection

Do you drink alcohol? If yes, how often? *

Do you use tobacco? If yes, what kind and how often? *

Are you an emotional eater? If yes, please describe. *

How often do you exercise? Please describe your current exercise routine. *

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