Medical Nutrition History

First Name: Last Name:

Birth Date:        Age:

Address:
              

City:    State:        Zipcode:

Phone:                                Email:

Occupation:

1. Personal Physician: ��� Date of your last exam:

2. What medications are you now taking?
   
3. Do you have any allergies (food or non-food) ? yes no
4. Have you had recent surgery? yes no
5. Do you have a familial history of obesity? yes no
6. Have you been diagnosed with or received treatment for any of the following medical conditions?� Check if you have and put the year occurred

Cancer����       Liver disease ���� ��� Arthritis               Kidney or bladder disease������� Crohn�s disease    
Diabetes        Hypoglycemia         Heart Disease      High blood pressure                 Celiac�s disease
Anorexia       Anemia                   Epilepsy               Thyroid disease                        Prostate disease
GI disturbances(IBS, ulcers)
Metabolic Syndrome includes the presence of three or more of these components: central obesity, high lipid levels, insulin resistance, high blood pressure, and high C-reactive protein�

7. Are you currently taking fertility drugs or are pregnant or breastfeeding? yes no
   

8. Are you currently taking any mood elevating prescriptions? yes no

9. Current abnormal lab values:

10. Please describe your weight history and past attempts at weight loss or modifying your eating habits.
    

11. Height: ft in.    Current weight (lbs): Usual weight (lbs): Goal Weight (lbs):

12. How many meals do you eat away from home in a week?

13. How many meals do you eat per day?

14. How many glasses of water do you drink daily?

15. Do you exercise, if so how often? yes no
    Once a week            2-3 times a week             4-5 times a week      5+ times a week

16. What is your goal for this nutrition counseling session?
    

17. Please record everything you had to eat or drink in the past 24 hours or on a typical day:
    

18. List the amounts of the following foods you consume on a daily basis:

Soft drinks___ Veggies___ Meat_____ Milk___ Fruit____� Legumes___
Oils___ Alcohol___ Whole grains_____

By typing my name in the box below, I understand that the information above will be confidential and is accurate to the best o f my knowledge.

Signature ����������� Date: