Integrative Nutrition Intake
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- Kory Jefferson
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1 Kristi Pink, MPH, RD, LDN Integrative Nutrition Integrative Nutrition Intake Sunu Wellness Center Ridgedale Dr Suite 203 Minnetonka, MN P: Patient Information: Last Name: First Name: Date: Mailing Address: Apt/Unit: City: State: Zip: Primary Phone: ( ) Secondary Phone: ( ) Emergency Contact: Phone: ( ) - How did you hear about us?: Occupation: Employer: Date of Birth: / / Age: Gender: Marital Status: S M D W Children Pets: Height: Current Weight: Any Recent Changes: What is your primary reason for seeking nutrition counseling? Previous Doctors seen/treatments/diagnosis for these symptoms: (Please print clearly) Current Medications (Prescription and OTC): Allergies: Are you pregnant? Yes No Number of pregnancies: Expectations: My goal is to meet and exceed your expectations, so please tell me: What are you hoping to receive from our time? Health Priority/Health Vision: 1 Sunu Chiropractic Inc 2017
2 If you could change THREE things about your health and nutritional habits, what would they be? Are these a priority for you right now? (readiness to change) Why or why not? How willing or ready are you to make changes in these areas on a scale of 1-5? What would be different about your life when (above) are achieved? (importance) What are the biggest challenges to reaching your goals (mentioned above)? (confidence) What have you tried in the past? And what were your experiences? What are your strengths? Was there a time when you were at your optimal health? What was different then vs. now? Nutritional Intake: Please describe any current dietary restrictions you may have (i.e. gluten free, vegan, food allergies, food intolerances, etc.) Where do you typically receive your nutrition/health information? How many meals are eaten per day? Do you typically eat breakfast? How many snacks? If so, at what time? 2 Sunu Chiropractic Inc 2017
3 Where are meals typically eaten? (circle all that apply) School Work Home Restaurant Car/Vehicle Other: How many persons reside in your household? Who usually does the grocery shopping? Who usually does the cooking? Do you enjoy shopping and cooking? Describe containers used for cooking and food storage (plastic, glass, etc.): What are you doing while eating meals/snacks? Sitting at the table Watching TV Riding/Driving Studying Other: When you are thirsty what do you usually reach for? Juice Soda/Pop Sport Drink Water Other: How much water do you drink per day? Where are you getting the water? (tap, bottled water, drinking fountain, other) Tell me about your alcohol consumption? How often and what type; wine, beer, cocktails, etc. Do you have open access to food and water or do you ask someone for help? What are your favorite veggies? In one day, how many times do you eat veggies? What colors are they? What are your favorite fruits? In one day, how many times do you eat fruit? 3 Sunu Chiropractic Inc 2017
4 How many times per day do you eat sweets like cake, cookies, candy, donuts, pop tarts, sugared cereal, soda, etc? What is a usual Breakfast: What is a usual Lunch: What is a usual Supper/Dinner: Do you usually do any snacking between dinner and bedtime? What do you usually snack on: Describe your relationship with sugar: Describe your relationship with food: When you have cravings, are they toward salty, sweet, etc..? Sleep: What time do you usually go to bed? What time do you usually get up in the morning? Do you ever wake up during the night? What activities do you do before bed time? (Circle all that apply) Homework Read Activity inside (non-electronic) Use electronic device Sports/Activity Outside Snack/eat/drink Watch TV Other: 4 Sunu Chiropractic Inc 2017
5 How do you wake up? On your own Someone wakes you up Alarm Clock Other: Do you feel rested when you wake up? Electronics: When do you use electronics during the day? In the morning Afternoon Evening Car/Bus What do you usually use electronics for? (Work, games, videos, TV, movies, talking with friends, homework, etc.)? Physical Activity: What are your favorite sports/activities? How much time are you active each day? (10 min, 15 min, half hour, more than an hour, etc) Describe what those activities consist of: i.e. cardio, yoga, strength training, etc. Symptoms: Do you ever feel or experience any of these symptoms? (circle all that apply) Achy Joints Autoimmune Disease Extreme Tired Itchy Eyes Skin Rashes/Eczema Acne Bloating Foggy Brain Irritability Stomach Aches Allergies Constipation Frequent Colds Leg Cramps Stress/Anxiety Asthma Digestive Problems Headaches Sad/Depression Urgent bowel movements Attention Difficulties Difficulty falling asleep Heartburn Sinus Infections Other: Do you have any allergies/sensitivities to food/environment? 5 Sunu Chiropractic Inc 2017
6 Family History: Supplements: What supplements and/or vitamins are you currently taking? Multivitamin Probiotics Omega 3- Fish oil Other: Stress: On a scale of 1-10 how would you rate your level of stress? How effective are you at handling your stress levels? What techniques help with this? Relationships: When you are successful with achieving your goals, who will be there to celebrate with you? On a scale of How would you rate your connectedness in relationships? (Partner, marriage, work, children, friends, etc.) What else would you would like me to know about you? 6 Sunu Chiropractic Inc 2017
City: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:
1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
Bariatric Patient Nutrition & Lifestyle History. What Bariatric procedure are you considering? Bypass (RNY) Sleeve
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Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Initial Client Questionnaire
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Phone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
Client Intake Form Please fill out the following questions as best you can. If there is a particular question you don t understand or want to fill out, we can discuss them at our first meeting. Thank you.
YOU ARE WHAT YOU EAT. 2. Do you eat more packaged (frozen or canned) fruits & vegetables than fresh?
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NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
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Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
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Nutrition Assessment
Today s Date: Basic Information Name: Age: Gender: Date of Birth: Phone Number: Email Address: I prefer to be contacted via (please circle): phone email Reason for your visit: Occupation: Do you have children?
Current Health Profile Please total scores on all pages and write the total at the end before
Name Date: Current Health Profile We ask these questions in order to locate potential causes of your current health problems. We are not here to judge you. Your honest answers will give us the ability
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
LIFE STYLE ASSESSMENT FORM. Name: Date: Age: Sex:
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First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
Date Time Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A
Emily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA (610)
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page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
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HEALTH HISTORY FORM. (Please fill out thoroughly and print clearly) Name: Date: Age: Male/female: Height: Weight: Weight one year ago:
HEALTH HISTORY FORM (Please fill out thoroughly and print clearly) Name: Date: Age: Male/female: Height: Weight: Weight one year ago: Would you like your weight different? If so, what? Street Address:
Do you exercise? Yes No If yes, what kind? How often?
HEALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss plan.
Nutrition Consultation Questionnaire
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Name Date of Birth Medical History Do you have any medical problems / major illnesses? Please list these with dates of diagnoses. Regular Medications Please list all current prescribed medications and
Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No
Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at
Weight Loss Profile. Do you exercise? Yes No If yes, what kind? How Often?
Weight Loss Profile Weight Loss Profile Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer