Name Age Gender Weight Height
E-MAIL ADDRESS: How did you hear of this site?
Heart DiseaseDiabetesObesityHypertensionCronic Obstructive Pulmonary DiseaseCancerHigh CholesterolInfectious Disease (describe under "other")Kidney FailureStrokeOther
Weight loss (How much/time frame)IntentionalUnintentionalWeight gain (How much/time frame)Usual Body Weight
Current Diet Food Allergies
Medications (Please include over the counter medications, herbal supplements, orany liquid nutrition supplements)
Do you smoke? Do you consume alcohol?
Yes Yes: How much/How often
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 DiseaseDiabetesObesityHypertensionCancer High CholesterolKidney Failure Stroke Other
24 Hour Diet RecallPlease record the TIME a food was eaten beginning with when you woke up in themorning. Next record the FOOD eaten and AMOUNT. It would be helpful to includehow 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.
How would you describe your appetite?
How many meals do you eat in 24 hours?
OneTwoThreeFour or more
Do you eat between meals?
Do you skip meals?
Do you have any difficulty chewing or swallowing your foods?
Are there cultural/ethnic issues that influence your daily food intake, forexample, do you exclude certain foods from your diet or consume a lot of acertain type of food. Please describe below.
It's important to have goals prior to your assessment so that we can tailoryour recommendations to help reach your goals. Please describe your goals inthe box below.
Additional information you may think is helpful to your assessment such as whatis 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 additionalinformation if need be.
Click "Send" and then hit "back" to return.