Initial Assessment Form – Adult

Date

Patient's Name

Occupation

Email

Gender

Age

Marital Status

Mailing Address

Phone (Cell)

Phone (H)


Primary Care Physician

Physician's Name

Physician's Address

Physician's Phone Number


Medical History

Height

Weight

Have you had a recent weight change?
YesNo

Was this weight change a gain or loss?

How much did you lose or gain?

Are you currently being treated by a physician? If yes, please explain.

Blood Type

Past Medical History - Do you have a history of any medical conditions?

Pregnant? Due Date


Lab Results

Date of last test

Total Cholesterol

LDL

HDL

TG

Blood Pressure


Blood Glucose

HbA1c

BUN

Creatinine

Other


Medications

Please list current prescription and non-prescription medicines, vitamins, minerals and herbal supplements.


Nutrition Goals

What are your nutrition concerns or reasons for visit?

If other, specify

Have you seen a Dietitian before?
YesNo

If yes, please explain when and why?

The biggest challenge(s) to reaching my nutrition goals is/are:

How did you hear about Wonderfully Nutritious Solutions?

Exercise

Do you currently exercise? Yes or No. 
If yes, what type of exercise?

How many times per week?

Types of exercises

For what length of time (minutes)?

How long have you been on this exercise program?

Do you have any condition that limits your physical activity? Yes or No.Explain

What obstacles have you found to previously prevent you from meeting your goals?

Hours of sleep per night

Describe your energy level

Describe Stress Level

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