Initial Consultation Form

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Last Name *

First Name *

Date of Birth *

Gender *

Address *

Phone Number (Home) *

Phone Number (Cell/other) *

Email *

Occupation *

Marital Status *

Food Allergies/ Intolerance/ Sensitivity

Current Height *

Please enter height in feet and inches. (Example: 5' 4" or 5 feet 4 inches)

Current Weight *

Please enter weight in pounds

Medical History *

If no medical history, please enter "None".

Family Medical History *

If no family medical history, please enter "None".

Medications/ Supplements *

If no medications/supplements, please enter "None".

I would like to see a dietitian because: *

My health and nutrition-related goals are: *

In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals *

Referring Clinician/ Primary Care Physician

Contact of Referring Clinician/ Primary Care Physician

Primary Insurance Carrier

Insurance Number

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Name of Primary Card Holder

Insurance Company Phone Number

How did you find Simply Nutrition NYC or Registered Dietitian Katrin Lee?

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