Nutrition Assessment - Diet Advisor
Nutrition Client Information Form
John W. Cartmell MS • 8226 196th Ave. NE • Redmond, WA 98053 • (425) 883-7444
Save this form to desktop before completing (click on attachment and choose “Save As”). Open and complete the form, save and close the file, then e-mail the completed form as an attached file to diet_advisor@
Alternately, you can bring the completed form with you to your appointment or complete it at that time.
Date
|Name | |
|Address | |
|City/State/Zip | |
|Phone | |
|Email | |
|Date of Birth | |
|Occupation | |
|Marital Status | |
|Referred by | |
|Height | |
|Weight | |
|Doctor | |
|Clinic Name or City | |
|Phone | |
|NPI # | |
|Diagnostic Codes: | |
|Currently Being Treated For | |
|Name of Insurance Plan | |
|Name of Policy Holder | |
|Policy Holder’s Address | |
|Policy Holder’s Phone | |
|Policy Holder’s Date of Birth | |
|Policy ID # | |
|Group | |
|Employer | |
|Insur Customer Serv. Phn # | |
|Is there another Health Plan? | |
Dietary Intake: List foods and beverages in oz or portion size (small-med-large)
|Breakfast | |
|Mid-Morning | |
|Lunch | |
|Dinner | |
|Snacks | |
Supplements
•
|Health Concerns - Underline or Bold All That Apply |
| | | | |
|Acid Reflux (GERD) |Allergies |Anemia |Anxiety Panic Attacks |
|Aspiration of Liquids |Asthma |Atherosclerosis |Athlete's foot |
|Bad breath or body odor |Belching After Eating |Blurred Vision |Bruise easily |
|Burning/Difficult Urination |Cancer |Cataract |Chest pain or tightness |
|Chronic Fatigue |Coated Tongue |Cold Feet Or Hands |Congestive heart |
|Constipation |Crave Carbohydrates |Crave Salt |Crohn's disease |
|Depression |Diabetes |Diarrhea |Drowsiness |
|Dry mouth |Ear Infections |Ears Ring |Eczema or dermatitis |
|Endometriosis |Excess Hunger |Excess Thirst |Excess urination |
|Fatigue after Eating |Feel Cold |Feel Full Hrs After Eating |Fibromyalgia |
|Fluid Retention |Food Sensitivities |Frequent Bowel Movements |Gall bladder problems |
|Gallbladder Removed |Glaucoma |Grind Teeth In Sleep |Headaches |
|Heartburn |Heart Problems |Hemorrhoids |Hiatal hernia |
|High Blood Cholesterol |High Blood Sugar |High Blood Pressure |High Liver Enzymes |
|High Blood Triglycerides |Inflammatory Bowel (IBD) |Indigestion |Intestinal gas bloating |
|Intestinal Pain/Cramps |Irregular Heartbeat |Irritability |Irritable bowel (IBS) |
|Itching or Rash |Lactose Intolerance |Lack Of Appetite |Lights bother eyes |
|Loss of Balance-Dizziness |Loss Of Taste Or Smell |Low Blood Pressure |Low blood sugar |
|Low-Fat Diet |Low Salt Diet |Memory Problems |Mood swings |
|Mouth Sores |Mucus In Stools |Muscle Aches Or Pain |Muscle Spasms/Cramps |
|Muscle Stiffness |Muscle Twitching |Muscle Weakness |Nasal congestion |
|Nausea |Nervousness |Numbness/ Tingling |Night sweats |
|Night Vision Problems |Osteoarthritis |Osteoporosis |Overweight |
|Post Nasal Drip |Premenstrual Syndrome |Prostatitis |Psoriasis |
|Rapid Heartbeat |Restlessness |Restless Legs |Rheumatoid arthritis |
|Chemical Sensitivity |Sensitivity To Noise |Shortness Of Breath |Sinus infections |
|Sleeping Problems |Sore Throat |Sore Tongue |Stomach pain |
|Sudden Loss of Libido |Sweat Easily |Sweating |Swollen ankles |
|Thyroid Problems |Trouble Concentrating |Trouble Swallowing |Ulcerative colitis |
|Urinary Incontinence |Urinary Retention |Vaginal Discharge |Vomiting |
|Yeast Infections |White Spots In Finger Nails | | |
Other Symptoms
•
|Lifestyle |Heavy |Moderate |Light |None |
|Alcohol | | | | |
|Tobacco | | | | |
|Caffeine | | | | |
|Sleep | | | | |
|Recreation | | | | |
|Stress | | | | |
Physical Activity Level - Check One
| |Little or no exercise |
| |Light Exercise/sports 1-3 days a week |
| |Moderate Exercise/sports 3-5 days a week |
| |Hard Exercise/sports 6-7 days a week |
| |Very Hard Exercise/sports and a physical job |
Medications and Conditions prescribed for (include birth control pills
•
Surgeries and Blood Type
•
Breast-fed as Infant?
• Yes
• No
Main Areas of Focus
•
Other Comments
•
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