DIETITIAN INTAKE FORM

Health and well-being are influenced by many different things, such as lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following form to give us an overview of your general lifestyle and health habits

Last Name*

First Name*

Address*

City*

Province*

Postal Code*

Telephone (Cell)*

Telephone (Home)

Email Address*

Date of Birth*

Family Doctor Name

Family Doctor Telephone

Reason for nutrition visit:*

Have you seen a Dietitian in the past?

Yes
No

If Yes, When:

Reason:

How did you hear about the Dietitian services?*

Examples: Referred by a doctor, referred by friend/colleague/family, advertising (brochures, banner, etc.), by chance/walk in, by employee staff, internet search, returning patient

Medical History

Height:

Weight:

Has your weight changed in the last 6 months?

Yes
No

If "Yes", please explain further:

Health Conditions (Check any that apply)*

Food Allergies/Intolerances:

Blood Tests

If you keep a blood glucose log or have any recent blood tests results(e.g. blood glucose,a1c,cholesterol), please bring to your appointment or email the clinic a copy.

Are you currently taking any medication or supplements?*

Yes
No

If "Yes", please list:

Family Health History

Please identify any significant health problems amongst your father, mother, siblings, grandparents (maternal and paternal), and/or children.

Lifestyle Habits

Occupation*

Schedule*

(day/evening/shift work)

I Live:*

Who does the grocery shopping?*

Who cooks?*

How often do you eat out?*

(i.e. Fast food/restaurants/cafeterias)

Are you dieting?*

Yes
No

If "Yes", are you on a physician prescribed medical diet?*

Yes
No

Have you experienced any of the following?*

Skip meals to reduce calories
Purging/making yourself sick after eating
Eat large quantities of food at one time
Over exercising
Use of laxatives for weight loss
Obsessive thoughts of food or weight
Feeling out of control when eating
None

# of meals you eat in a day:*

# of snacks you eat in a day:*

How would you rate your salt intake?*

Low
Moderate
High

How would you rate your fat intake?*

Low
Moderate
High

Do you drink Caffeine?*

# of cups/cans per day:*

Are you a smoker?*

Yes
No

If "Yes", smoking history:*

Do you drink alcohol?*

Yes
No

If "Yes", how often?*

Do you drink:*

Mixed drinks
Beer
Wine
Liquor

Physical Activity*

Types of physical activity:

Mental Health

Stress Level

Low = 1 and High =10

Source of Stress:

Do you have problems with eating or your appetite when stressed?*

Yes
No

Hours of Sleep per night:*

Any sleep interruptions?*

Yes
No

If "Yes", please explain:

Self-Assessment

What is your health goal?

What is your biggest obstacle to reaching your goal?

On a scale of 1 to 10, how would you rate the importance of making changes to benefit your health?

Not important=1 and Very important= 10

On a scale of 1 to 10, how would you rate your readiness to making changes to benefit your health?

Not Ready=1 and Very Ready= 10

On a scale of 1 to 10, how would you rate your confidence that you will be successful in making changes to benefit your health?

Not important=1 and Very important= 10

What is your favourite food?

Consent

I, ___________________________________________ hereby consent permission for the Registered Dietitian to provide nutrition counselling to myself or the client for which I am legally responsible. I understand that the Registered Dietitian does not provide medical advice, nor will they diagnose medical conditions. The Registered Dietitian may provide me with nutritional support and education that relates to already diagnosed nutritionally related conditions. Nutrition assessments are intended to be a guide for enhancing my nutritional health and supporting my athletic goals. I accept that it will be necessary for the Registered Dietitian to collect personal, health, and lifestyle information. Medical records and personal information and history will be kept confidential, unless I consent to sharing my medical information. Further, if I would like nutritional advice provided through web-supported platforms(Zoom, Telehealth, etc), I understand and accept that internet associated activities are inherently at risk for a breach of personal information. I understand that if I schedule a web-based session that this implies consent and understanding of these risks. I have agreed to have my Registered Dietitian keep records of our visits and to file these in a secure and appropriate place. I have agreed to have the Registered Dietitian contact other Health Care Professionals to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax or email.*

First Name, Last Name

Date*

Witness

First Name, Last Name

Name

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