pre-visit form

Pre-Visit Form

Before your first visit, please fill out the form and submit, or click here to download a printable form for you to bring in with you to your visit.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth*
Month
Day
Year
Gender
- Female
- Male
Please List Any Known Food Allergies
Reason for Appointment
Medical History
Name of Physician
Physician's Phone
Any Pertinent Labs
Current Medications
Supplements
Height
Weight
Weight History
How often do you exercise?
Describe Type, Duration, and Frequency of Exercise
Work Status (if working – type of work, hours/wk)
Living Situation (shared meals? Eat alone?)
Energy Level (0-10)
Stress Level (0-10)
Average Hours of Sleep Per Night
Alcohol (quantity, frequency)?
Tobacco (cigarettes/day)?
Other Drugs?
How is your appetite?
Who shops for food and where?
If cook, who does it?
How often do you eat out in a week (where)?
Food Cravings
Food Dislikes
Short-Term Goal(s)
Long-Term Goal(s)
What challenges do you foresee in acheiving your goals?
Any Other Information
Agreement*
I understand I will be charged for the full rate of each missed nutrition session if I do not call ahead with at least 24-hour notice, and these sessions will not be able to be made up in the future. I agree to pay for the full amount for the session at the time of service or, if a package deal, the full amount at the time of the first session (cash or personal check only; no credit cards). I agree to pay any amount that is not covered by my insurance. Prepaid appointments must be used within 3 months of purchase and weekly packages must be used within the allotted weeks. Unused sessions will be lost. I have read the above statements and understand the rescheduling protocol for my nutritional counseling sessions.
- Check here to accept the above terms and conditions.
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pre-visit form

Pre-Visit Form

Medical History