Individuals who are referred to a nutritionist or dietician for outpatient nutrition counseling are eligible to fill out this form.
When were you last seen by a dietitian or nutritionist?
Why are you here today?
What are your eating patterns like?
What are your thoughts about your diet?
What are your food likes and dislikes?
What are your current eating habits?
What, if any, changes would you like to make to your diet?
What are your current health concerns?
What are your current medications?
Do you have any food allergies or sensitivities?
What are your height and weight?
What is your waist circumference?
What is your body mass index (BMI)?
What is your percent body fat?
What is your daily energy expenditure (DEE)?
What is your basal metabolic rate (BMR)?
What is your target heart rate (THR)?