...an introduction to medicine that tastes good. Registration + Intake Form
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1 Registration + Intake Form Instructions Please give yourself enough time to fill out this comprehensive form. You will need to it once payment is made to food101program@gmail.com. Do not your Food + Reaction Recall Diary (last page of the Registration + Intake Form). Instead, bring it to the first class and be prepared to hand it in at that time. If you need more room to answer completely, feel free to write on the back or add an additional page. PREREQUISITE: Must be willing and eager to learn to cook. PLEASE NOTE: This course is not appropriate for those with Type-1 Diabetes Meletis Lynn Ogryzlo, CNP Program Director + Culinary Nutritionist lynnogryzlo@gmail.com INTAKE FORM
2 Registration + Intake Form Date: Name: Address: Date of Birth: Age: Weight: Height: Male/Female: Address: Occupation: Hrs/week: Health Care Providers + Contact Info: How would you rate your general health: Poor Fair Good Excellent List the health goals that you would like to work on: Do you - Smoke: for how long: Drink alcohol: How Much: Exercise: Y / N Kind of exercise + frequency: On a scale of 1 to 10, rate your stress level and say why: INTAKE FORM Page 1
3 How is your concentration focus? Hours of sleep/night: FOOD How would you rate your diet: Poor Fair Good Excellent Would you say you eat a well-balanced, healthy diet? Why (not)?: If you think you can eat better, what is stopping you? What foods do you crave? When do you crave these foods? Any Food Allergies/Sensitivities that you know of?: What happens when you eat these foods? Do you eat regularly? Do you eat when you re hungry? or stressed?: List 10 of your favourite foods: Do you like to cook? What are two of your favourite dishes to cook? If you do not cook, why? Are you wiling to learn to cook? Do you eat in front of the TV/Screen?: How often?: Do your family members eat the same dinner each evening? different dinners? INTAKE FORM Page 2
4 How many times a week do you cook? How many times a week do you eat out? When you eat out, what is your favourite restaurant? Why: Do you tend to order the same foods at the same restaurants? Have you ever been on a diet before? Diet Reason Result Practically speaking, what kind of support do you think you need to achieve your health goals? I understand the information in the, an introduction to medicine that tastes good program is of a nutritional nature and not intended as a medical diagnosis or medical advice. It is strongly recommended that you inform your doctor that you intend to participate in a plant-based, Mediterranean-style nutritional program. This program is not appropriate for anyone with Type-1 Diabetes Mellitus (T1DM). By signing this form you are declaring you do not have T1DM. Signature Date INTAKE FORM Page 3
5 Food + Reaction Recall Diary Please record the food and drink you consume over a 4 day period and indicate how you feel (gas, bloating, headache, tired, stiff joints, etc) Meals Day 1 Day 2 Day 3 Day 4 Breakfast: Lunch: Dinner: How I Felt INTAKE FORM Page 4
Johnson City Internal Medicine 301 Med Tech Parkway, Suite 240, Johnson City, TN (423)
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Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
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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:
LIFE STYLE ASSESSMENT FORM. Name: Date: Age: Sex:
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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:
Emily Murray MS, RD, LDN Nutritionist / Registered Dietitian 110 West Lancaster Avenue Wayne PA (610)
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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
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Integrative Nutrition Intake
Kristi Pink, MPH, RD, LDN Integrative Nutrition Kristi@sunuwellness.com Integrative Nutrition Intake Sunu Wellness Center 12455 Ridgedale Dr Suite 203 Minnetonka, MN 55305 P: 952.314.7035 www.sunuwellness.com
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Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
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