New Client Initial Assessment Form

Patient Name

Email Address

Today's Date (MMDDYYYY)

Age

Primary Phone Number (XXX-XXX-XXXX)

Gender Gender Male Female

Height (e.g. 5'7")

Weight (e.g. 155)

Have you had recent weight change? Have you had recent weight change? Yes No

Was this weight change a gain or a loss? Was this weight change a gain or a loss? Gain Loss

How much weight did you gain or lose?

Are you under physician care? Are you under physician care? Yes No

If yes, explain reason for being under physician care

Medical History Medical History None Arthritis Cancer Eating Disorders Heart Disease Shortness of Breath Kidney Disease High Blood Pressure Osteoporosis Liver Disease Renal Disease Diabetes Food Allergies Hypoglycemia Thyroid Autoimmune Disease (e.g. Fibromyalgia, Lupus, etc) Gastrointestinal Concerns (e.g. Constipation, Diarrhea, etc) GERD (e.g. Heartburn, Reflux) High Cholesterol (e.g. Total Cholesterol, LDL, Triglyceride) Weight Concerns (e.g. Overweight, Underweight) Other

Are you pregnant? Are you pregnant? Yes No

What's your due date? (MMDDYYYY)

Date of last lab test? (MMDDYYYY)

Total Cholesterol

HDL

LDL

Blood Pressure

Blood Glucose

B.U.N.

Creatine

List all medications you're currently taking

Nutrition Goals/Concerns Nutrition Goals/Concerns General Nutrition (Eating Better, Wellness) Gastrointestinal Heart Health Sports Nutrition Vegetarian Meal Planning Weight Management Anemia Diabetes Eating Disorder Other

If other nutrition goal, please specify:

Have you seen a dietitian before? Have you seen a dietitian before? Yes No

If you've seen a Dietitian before, explain why:

What do you see as the biggest challenge to reaching your nutrition goals?

How did you hear about Wonderfully Nutritious Solutions?

Do you exercise? Do you exercise? Yes No

If yes, what types of exercises?

How many times per week?

How long do you usually exercise?

How long have you been on this exercise program?

Do you have a condition that limits your physical activity? If yes, please explain...

Number of hours of sleep per night?

Describe your energy level

Describe your stress level