Name        Age        Gender

		Weight          Height     


E-MAIL ADDRESS: How did you hear of this site?


DIAGNOSIS
Heart Disease
Diabetes
Obesity
Hypertension
Cronic Obstructive Pulmonary Disease
Cancer
High Cholesterol
Infectious Disease (describe under "other")
Kidney Failure
Stroke
Other

WEIGHT HISTORY
Weight loss (How much/time frame)IntentionalUnintentional
Weight gain (How much/time frame)
Usual Body Weight                


Current Diet 		Food Allergies



Medications (Please include over the counter medications,  herbal supplements, or
any liquid nutrition supplements)


Do you smoke?			Do you consume alcohol?
Yes				Yes: How much/How often 
No				No

Laboratory Values (Within past year if available)

Total Cholesterol     LDL Cholesterol  HDL Cholesterol
Albumin    HgbA1c (Diabetes)   Blood sugars (Diabetes)

FAMILY HISTORY (Check ALL that apply)

Heart Disease
Diabetes
Obesity
Hypertension

Cancer 
High Cholesterol
Kidney Failure 
Stroke 
Other




24 Hour Diet Recall

Please record the TIME a food was eaten beginning with when you woke up in the
morning. Next record the FOOD eaten and AMOUNT. It would be helpful to include
how foods were prepared and/or whether the food was from a restaurant.
When recording the amounts, record liquids in ounces, whole fruits and vegetables in pieces,
cooked fruits and vegetables using measuring cup sizes, meats in cooked ounces,
cooked or ready-to-eat cereals, rice, pastas in measuring cup sizes.
Example: 8am, toast, 2 slices;  10am, apple, 1 piece; 5pm, chicken(fried),
3 ounces;  9pm, milk(whole), 8 ounces.






APPETITE

How would you describe your appetite?  
ExcellentGoodFairPoor

How many meals do you eat in 24 hours?
OneTwoThreeFour or more


Do you eat between meals?
Yes,      Describe
No



Do you skip meals?
Yes,      When
No
                


Do you have any difficulty chewing or swallowing your foods?
Yes, Describe
No


Comments



Are there cultural/ethnic issues that influence your daily food intake, for
example, do you exclude certain foods from your diet or consume a lot of a
certain type of food.  Please describe below. 





Goals

It's important to have goals prior to your assessment so that we can tailor
your recommendations to help reach your goals.  Please describe your goals in
the box below.



Additional information you may think is helpful to your assessment such as what
is your daily activity level?  If you have a work-out schedule please describe.  



 Once your information is reviewed, I may be e-mailing you for additional
information if need be. 


Click "Send" and then hit "back" to return.


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