Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First and last name & any nicknames you prefer: *Birthday: *Email *Phone Number *Height *Weight (lbs) *Gender:MaleFemalePrefer not to answerAge *Occupation:What does your typical work hours/week look like? What is your purpose for filling out this form today? *What are your main health concerns/complaints? Please list in priority. *HEALTH & MEDICAL HISTORYDo you have any medical conditions? (e.g. diabetes, high blood pressure, PCOS, thyroid conditions, etc.)If yes, please list:Do you have any food allergies or intolerances?If yes, please list:Are you currently on any medications or supplements?If yes, please list:Have you recently had any lab work or diagnoses that may impact your nutrition (e.g., iron deficiency, cholesterol levels, blood sugar)?If yes, please explain:LIFESTYLE & ACTIVITYHow active are you on a typical day? *What type of exercise do you currently do (if any)? *How many hours of sleep do you get per night on average? *How would you rate your stress levels?LowModerateHighWhat level of stress do you feel you are experiencing at this time? Please quantify on a scale of 1 (low) to 10 (high): Do you use any coping mechanisms?NUTRITION & HABITSDo you have any dietary restrictions or preferences?(e.g. vegetarian, keto, dairy-free, halal, etc.)How many meals per day do you typically eat? *Do you skip meals often?YesNoDo you drink coffee or tea? *If yes, how many cups/day and what do you add (cream, sugar, etc.)? Do you consume alcohol?If yes, how often? On a typical day, what does your food intake look like? *Give an example of what you ate yesterday or on a regular weekdayDo you have any binge-eating or emotional eating patterns you'd like to share?If yes, please describe briefly:PROGRAM GOALS & EXPECTATIONSWhat are your primary goals for this program?e.g. weight loss, more energy, better digestion, muscle gain, consistency, etc.What has been your biggest challenge with food or nutrition in the past?Are there specific foods or meals you love and would like included in your plan?Are there any meals/ingredients you dislike or prefer to avoid?Is there anything else you'd like me to know before your consultation?SUBMIT TDC Nutritionisttdc form test – nov 1611.16.2020
