Nutrition First Because it matters.

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LuAnne Petrie Nutrition Consultant MS, RD, CDE Nutrition First Because it matters. 415 State Route 34 Colts Neck NJ 07722 info@nutritionfirstllc.com www.nutritionfirstllc.com (908) 692-4140 BACKGROUND INFO NUTRITION HEALTH ASSESSMENT NAME (First, Last) STREET CITY, STATE, ZIP TELEPHONE Home ( ) Work ( ) Cell ( ) EMAIL PRIMARY CARE PHYSICIAN: STREET CITY, STATE, ZIP Phone: Email: PRIMARY INSURANCE PROVIDER: Primary Insurance Holder: Relationship: Group # Member ID# SECONDARY INSURANCE PROVIDER: Secondary Insurance Holder: Relationship: Group # Member ID# GENDER: M F HEIGHT: CURRENT WEIGHT: AGE: DATE OF BIRTH : ETHNIC BACKGROUND MARITAL STATUS 1. White, not of Hispanic background 1. Single 2. Black, not of Hispanic Background 2. Married 3. Hispanic 3. Widowed 4. American Indian/Alaskan native 4. Divorced/Separated 5. Asian 6. Pacific Islander

PRIMARY REASON FOR VISIT: DIET HISTORY Usual Weight Have you lost or gained any weight over the past year? YES NO If yes, please explain. Do you have any food allergies or intolerances? YES NO If yes, please list. Are you currently on a special diet? YES NO If yes, explain. Have you followed any diets in the past? If so, please describe: How many times per week do you eat at restaurants or consume take-out or fast food? Please describe what you believe are your eating issues. (e.g. Do you have problems with portion control? Do you binge eat? Are you a stress eater?)

FOOD/BEVERAGE DIARY Please record the time of day and your food and beverage intake for an average day. Meal Time Food Breakfast Lunch Dinner Tips for Keeping an Accurate Food Diary Your initial meal plan will be based largely upon your individual goals and your food recall. Keeping a food record will benefit our review of your current food habits. It may feel like an imposition, but this information will help us as we design an eating program to meet your specific needs. Here are some basic rules to help you document your eating habits:. Do it now Do not depend on your memory at the end of the day to record your eating - record as you go. Keep your food record with you; write down everything you eat and drink, including the time. A piece of candy here, or a handful of pretzels there, a glass of juice, or a small donut may not seem like much, but knowing about these snacks will help us to better assess your needs and current food behaviors. Be specific If you ate a burger with cheese, gravy on your meat, butter on your vegetables write it all down. Be honest - if you eat French fries, don t write down potatoes being fried makes a difference. Estimate amounts If you eat a piece of cake, estimate the size (2 x1 x3 ). If you eat a vegetable, is it ½ cup or 2 cups? (a clenched fist is approximately a one cup serving). When eating meat, record the size or estimated weight (a piece that is the size of deck of cards is 3-4 oz; if the packaging label on your dinner steak says 1 ½ lbs., and you ate half of it, write down ¾ lb.) Do the best you can!

MEDICAL HISTORY** Have you or a blood-related family member ever been diagnosed with the following conditions? Self / Family Self / Family Self/Family Cardiac arrhythmia Asthma Hypothyroid Elevated cholesterol Stroke Hyperthyroid Diabetes Type I Depression Alcoholism Diabetes Type II Heart disease Arthritis Kidney Disease High blood pressure Overweight/obesity Eating Disorder (specify)* Cancer (specify type)* Other (explain)* *Explanation In addition, please check all that apply to you. Depression PCOS Diverticulosis Vomiting Chronic constipation Acid Reflux/GERD Anemia Ulcers Nausea Chronic fatigue Diarrhea Smoker IBS Do you take vitamins/minerals or herbal supplements? YES NO If yes, please list. List any medications you are currently taking. Are you pregnant? Yes No If yes, how many weeks? Are you breastfeeding? Yes No **If available, please bring a copy of recent lab work

ACTIVITY Please complete the chart with activities you may do in your free time or practice regularly. Activity and Intensity* Length of Time (in minutes) Times Per Week Times Per Month * Low = if you are moving but heart rate and breathing remain the same Moderate = if your breathing and heart rate increase High = if you are unable to carry on a conversation during the activity SLEEP What time do you usually go to bed? What time do you usually wake up? Do you usually feel rested when you get up? OTHER Please list any concerns or information you would like to discuss that have not been addressed anywhere within this form.

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