SHARE Center Nutrition Questionnaire

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Please answer the following questions as thoroughly and accurately as possible for review by our dietician. Upon completion, you will be contacted directly to set up a consultation.

Please type your full legal name. *

Please provide your date of birth. *

YYYY

Please provide your legal gender. *

Male

Female

Prefer not to say

Please provide your email address. *

Please provide your phone number. *

Please explain why you would like nutrition counseling. *

Weight Management

General Healthful Eating

Diagnosis of Nutrition-Related Chronic Disease

Other:

Please list your past and present medical conditions (i.e. diabetes, high blood pressure, etc.). *

Please list all current prescription and non-prescription medications you take. *

Please list any dietary supplements that you take. *

I would like to lose weight. *

True

False

Please describe your current level of physical activity. *

Do you have any food allergies, intolerances, or religious restrictions when it comes to food? If so, what are they? *

Do you prefer an in-person appointment or telehealth? *

In-person

Virtual/Telehealth

No Preference

Please describe a typical day's meal plan including the times you normally eat. If known, include snacks, beverages, desserts, or other daily habits. *

I understand that the SHARE Center Free Clinic uses and discloses patient health information to provide treatment and for healthcare operations, including administrative purposes. I also understand that the SHARE Center Free Clinic uses and discloses health information for treatment activities and healthcare operations provided by another healthcare provider or institution. By typing my name below, I consent to such use and disclosure of the patient’s information. *

I understand that I have the right to refuse specific treatments and procedures. However, by typing my name below, I agree, in general, to permit x-rays, laboratory tests, routine medical treatments, emergency procedures as necessary, and hospital service performed at the request of the attending physician or other physicians assisting in my care. The attending physician is responsible for the patient's care. *

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