Please print the form and fill it out.
Bring it with you to your appointment with Holly Weber.
Contact Holly to make your appointment.
CONTACT
NUTRITIONAL HISTORY
NAME: ___________________ BIRTHDATE: ____________AGE:______ SEX: M __ F__
ADDRESS: __________________________________________________ DATE ______
TELEPHONE _________________ CELL PHONE ______________
E - MAIL __________________
WHAT BRINGS YOU HERE TODAY?
WHAT ARE YOU CURRENT MEDICAL CONDITIONS? (Please list)
1. How many meals and snacks do you eat each day? Meals_______ Snacks_________
2. How many times a week do you eat the following meals away from home?
Breakfast______ Lunch______ Dinner_________
3. What types of eating places do you frequently visit? Fast food ___ Diner/cafeteria____
Restaurant____ Other ___
4. On average how many pieces of fruit or glasses of juice do you drink each day?
Fruit _____ Fruit juice(8 oz cup) _____
5. On average, how servings of vegetables do you eat daily? _____
6. On average, how many times per week do you eat a high- fiber breakfast cereal? ______
7. How many times a week do you eat red meat? (beef, lamb, veal) or pork? ____
8. How many times a week do you eat chicken or turkey? _____
9. How many times a week do you eat fish or shellfish? ______
10. How many hours of television do you watch every day? ____
Do you usually snack while watching television? Yes____ No_____
11. How many times a week do you eat desserts and sweets? _____
12. What types of beverages do you drink? How many servings of each do you drink a day?
Water______ Milk: Alcohol:
Juice_______ Whole milk_____ Beer_____
Soda_______ 2% milk ______ Wine____
Diet soda _______ 1 % milk ______ Hard liquor_____
Sports drinks ______ Skim milk ______
Caffeinated Tea _____ Soy milk ______
Decaffeinated Tea______ Other milk______
Caffeinated Coffee_____ Decaffeinated Coffee_____
WHAT PRESCRIPTION DRUGS , INCLUDING DOSAGES ARE YOU TAKING? (Please list)
Name dose (mg/gms/mcg) time(s) per day
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ARE YOU TAKING VITAMINS OR SUPPLEMENTS? (Please list)
Name dose (mg/gms/mcg) time(s) per day
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