Preconsultant Questionnaire Form

* = Required Information

Patient's Full Name: *

Patient's Date Of Birth: *

Address: *

Phone: *

Patient's Signature: *

Date: *

Please answer the following questions as honestly and as detailed as possible before we schedule an actual consultation session:

1. Why do you want to undergo nutrition counseling?

2. Are you currently taking any form of medication?

3. Please give a brief summary of your medical condition.

4. Are you allergic, intolerant or have any religious restrictions to any type of food?

5. Do you smoke?

Yes

6. Do you consume alcohol?

Yes

7. Do you frequently exercise or are involved in any sporting activities?

Yes

8. What are your goals for taking nutritional counseling?

9. Please give a brief food history to include: breakfast, lunch, dinner/supper , snack?