Nutrition and Wellness Intake Assessment
Please fill out this form mindfully and completely. My ability to help you improve your present state of health depends significantly on complete, accurate answers to the following questions, as health concerns are often influenced by several factors. To enhance your scheduled consult time, please complete this assessment at least 72 hours before your initial appointment. Thank you! I look forward to serving you.
Welcome to Eating with Ease !
Basic Information
Today's Date *
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First and Last Name *
Your answer
Date of Birth *
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Street Address, City, State, ZIP *
Your answer
Phone Number *
Your answer
Marital Status
Income Level
Are you currently a student?
What is your occupation? *
Your answer
How stressful is your job? *
What is the last grade of school you completed? *
Your answer
If applicable, what was your major?
Your answer
Emergency Contact Name and Phone Number:
Your answer
How did you hear about us? *
Have you previously tried to change your diet in any way?
If so, what changes did you try?
Your answer
Understanding Your Needs and Goals
Please clearly define what you would like to achieve so we can best serve you.
What is your primary reason for seeking nutritional counselling?
Your answer
What is/are the health challenge(s) for which you are seeking guidance? If applicable, how long have you had this/these condition(s)?
Your answer
Please select all that apply to you:
Health History
Please indicate your past and present health concerns.
Please indicate if you *currently* have any of the following symptoms or ailments: *
Required
Please indicate if you have had any of the following symptoms or ailments *in the past:* *
Required
Do you have any dental or oral problems?
Please list any major childhood health issues and the age(s) at which they occurred:
Your answer
Please indicate significant medical history and specify maternal or paternal side of your family:
Your answer
Please list all medications you are currently taking and their dosages:
Your answer
Please list all supplements you are currently taking and their dosages:
Your answer
** Please bring all medications and/or supplements with you to your appointment. Thank you **
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