Nutrition & Medical History Questionnaire

Please complete to the best of your ability prior to your initial consultation.

Name

First Name

Last Name

Date

Email

Reason for your appointment:

Is there anyone involved in your care with whom we may share your medical information?

Please list names and contact information if available.

How did you hear about us?

Returning patient

Television/Radio

Doctor’s referral

Newspaper Ad

Spouse/Family Member

Web Search/Internet

Coworker

Other - please list below

Date of your last nutrition assessment/RD evaluation

MM

DD

YYYY

List any additional health information that you feel is relevant to today’s visit:

List any medications or supplements you are currently taking:

Your narrative:

Please write a brief summary of any things else that will be helpful to us regarding your health and medical history. What is your food story, your fitness goals, your wildest dreams about health and wellness: