Please enable JavaScript in your browser to complete this form.First Name *Last Name *Email *Phone Number *Sex *Height *Weight (lbs) *Age *What is your purpose for filling out this form today? *What are your main health concerns/complaints? Please list in priority. *What level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high): *What are the major causes or factors of your stress? (i.e. financial, career, personal, marriage, health, family, spiritual, unfulfilled expectations) Rate all that apply on a scale of 1 (low) to 10 (high) *How does your stress manifest itself? *Do you use any coping mechanisms? *What do you do for exercise? (frequency, type, time of day and duration) *On a scale of 1 (low) to 10 (high) how would you describe your energy levels? *How many hours on average do you sleep daily? (include naps) *What time do you go to sleep? Awaken? *Do you have trouble falling asleep? *YESNOTrouble staying asleep? *YESNODo you awaken feeling rested? *YESNODo you snore? *YESNOWhat is your occupation? *Do you enjoy your work? *YESNOHow many hours each day do you work? *At what times do you start and end work? *Do you work shifts or are you on a regular schedule? *Do you smoke? If yes, how much and for how long? *If no, does anyone in your household or workplace smoke? *Do you wish to gain weight? Lose weight? How much. *By when do you wish you reach your goal weight? *What is your main motivation to change your weight? *How many hours do you spend daily, on average: 1. driving 2. watching television 3. reading 4. in front of computer *What are your interests and hobbies? *Do you vacation regularly? *When was your last vacation? *Do you actively participate in any spiritual discipline? (church, religious groups, meditation, etc) *MessageSUBMIT TDC Nutritionisttdc form test – nov 1611.16.2020
