Nutrition Assessment Questionnaire

Full Name*

First NameMiddle InitialLast Name

Email*

example@example.com

Date of Birth*

Date

Phone Number*

Area CodePhone Number

1. Describe your current health lifestyle

a. Needs work, but not ready to make changes

b. Great! I follow a healthy lifestyle byblanks
c. Needs work, but ready to make changes toblank

2. Describe your current weight (normal, overweight, underweight) and how you feel about it:

3. Describe your current eating habits (grazer, binge eater, sugar/salt craving, balance diet, etc.)

4. What time is your first meal or beverage (besides water or black coffee) of the day?

5. What time is your last meal (snack/beverage) of the day?

6. How much water do you drink:

Not sure - Not enoughNot sure - I think I drink enough

I drink blanks oz each day

7. Do you take any supplements (multi-vitamin, protein shakes, etc.)?

NoYes

If yes, which one:blanks

How many days a week do you eat/drink:

Fishblanks
Processed sugar (cookies, ice cream, etc.)blank
Sugar sweetened beverage (soda, juice, etc.)blank
Diet drinkblank
Alcoholic beverageblank
Beans/Lentilsblank
Nuts/Seedsblank
Berriesblank
All other fruitblank
Cruciferous vegetables (broccoli, cauliflower, brussels sprouts)blank
Dark leaky green vegetables (spinach, kale, arugula)blank
Fast foodblank
Processed meat and cheeseblank

How many times a week do you eat out: blanks
Foods you love (and cannot live without): blank
Foods you dislike:blank
What obstacles do you face when trying to improve diet:blank

1. How many hours of sleep on average do you get each night?

2. How do you feel about your sleep quality/quantity?

3. What is "exercise" for you?

4. How many days a week do you exercise?

5. How many minutes a day do you spend exercising or moving?

6. Rate your stress on a scale of 1 to 10 (10 being the highest)

7. Where does stress originate (work, school, family, etc.)?

8. Do you struggle with any other psychological issues (anxiety, depression, worry, loss of interest, etc.)?

9. Have you ever seen a therapist/counselor/psychologist/psychiatrist? If yes, please state which one and what for.

10. What do you consider rest? (reading, going to the beach, spending time with family, etc.)

11. How many times have you been on an antibiotic regimen in your adult life?

Never1-34+

12. Have you taken antibiotics in the last year?

NoYes

If yes, when blanks

13. Have you done genetic testing (23and Me, Ancestry DNA), nutrient analysis, or Microbiome stool test?

NoYes

If yes, which one blanks

On a scale of 1-10, how likely are you to make dietary changes?

What do you need most out of this visit with the dietitian?

Please share any other pertinent information about diet and lifestyle

Thank you for filling out this questionnaire!

1. Services: The purpose of nutritional counseling is to improve the overall health, vitality and well-being of the body and quality of life through nutritional education and the use of natural foods and nutritional supplements. The Registered Dietitian Nutritionist, Daniele Kuhn is not
licensed to diagnose medical conditions.
2. Information Sharing: Client agrees to provide accurate and complete information regarding their medical history, dietary habits, lifestyle, and other relevant details. This information will be used solely for the purpose of providing personalized nutritional recommendations and is strictly confidential under HIPAA regulations.
3. Suspected Conditions: If, during the course of Services, RDN suspects the presence of a medical condition, Client will be promptly informed and strongly advised to consult a licensed physician for diagnosis and treatment.
4. Disclosures and Client Responsibilities: Client acknowledges their responsibility to disclose any known medical conditions and to consult with a licensed physician when necessary. Client agrees not to alter or discontinue any treatments prescribed by other healthcare professionals without first obtaining their consent.
5. Recommendations and Client Responsibility: Client acknowledges that any recommendations provided by RDN regarding dietary changes, or the use of nutritional supplements are based on the information provided by Client. Client assumes full responsibility for following these recommendations.
6. Release of Liability: Client agrees to assume all risks associated with participation in the Services, including any injury or death that may result. Client hereby releases and holds harmless RDN, its successors, and assigns from any and all claims, causes of action, and damages arising from such participation, whether caused by negligence or otherwise.
7. Telehealth Services: The Services may be delivered through a HIPAA-compliant telehealth platform, Doxy.me. Client agrees not to hold RDN liable for any breach of confidentiality arising from the use of this platform.
8. Payment: Client agrees to pay RDN the agreed-upon fees for Services prior to each appointment.
9. Termination: Either party may terminate this waiver upon written notice to the other party.Client remains responsible for all outstanding fees for Services rendered up to the date of termination.

BY SIGNING BELOW, CLIENT ACKNOWLEDGES THAT THEY HAVE READ,
UNDERSTOOD, AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN
THIS LIABILITY WAIVER.

I consent to treatment by Beautiful Minds Medical, Inc. for nutrition counseling as provided by the professional staff of Beautiful Minds Medical, Inc.

By signing below, I agree that all information above is true*

Nutrition Assessment Questionnaire

Food Frequency Questionnaire

Lifestyle Questions

Liability Waiver