NUTRITIONIST PRE-APPOINTMENT SURVEY

NUTRITIONIST PRE-APPOINTMENT SURVEY
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
Directions: To maximize our 50-minute session, it is helpful to think forward and communicate your needs. Needs are based on what drives you to set up nutrition counseling. Please email this completed survey prior to your nutritionist, prior to your appointment, or print it and bring it to your first appointment. Thank you.
Section 1. - Nutrition and Health Concerns
1. Are there any health conditions that do, or should, impact your food choices? List all that apply:*
2. Have you met with a licensed dietitian/nutritionist in the past for nutritional guidance? If so, when?*
- What was the reason you had nutritional guidance?
- Have you had nutritional guidance from another source? Please describe.
3. When you are seeking nutrition information, where do you usually get it? (Books, internet, friends/peers, sports trainers, alternative medicine sources, physician, pharmacist, dietitian/nutritionist, others)*
4.What is your current height?Height*
What is your current weight? Weight*
5. Please list any food allergies or intolerances:
6. Please list any and all medications (over the counter and/or prescription) and/or supplements you are taking, including dosages:*