Healthy Living Program ---
MMC (305) 348-2401 Ext. 5
Name: __________________
Panther ID#:__________________
Date: _____________
Hello Healthy Panthers,
Congratulations on taking a step to a healthy lifestyle! Please read and follow the guidelines
below in order to get the most out of your appointment.
Forms should be emailed to shsdiet@fiu.edu or handed in person to the Healthy Living
Program at least 3 days before your appointment. This allows the Dietitian to prepare
for your appointment and give you the best experience.
If the form isn’t turned in ahead of time, the length of your appointment will be impacted.
If you can’t make your appointment, cancel it within 24 hours to avoid being charged
the missed appointment fee. You may do so online at studenthealth.fiu.edu in the
myhealthinfo tab or by calling the office.
If you have any further questions or concerns please call the Healthy Living Program office at
(305) 348-2401 Ext. 5
Sincerely,
Christine Tellez, MS, RD
Nutrition Consultation Assessment Form
(Please answer to the best of your ability all information is confidential)
Email ____________________ Phone: (
) _______-_________ Gender ____M ____F
Age_____ Height______
Living situation ____On campus ___Off campus
If off- campus what is your living situation? (Example: with family, roommates, live alone)
______________________________________________________________________________
Reason for nutrition consultation: (Check all that apply)
Anemia/ low energy
High blood pressure
Gain weight
Nausea/diarrhea/
constipation
Diabetes
High Cholesterol
Lose weight
Crohn’s/Colitis/
other GI________
Disordered eating
Irritable bowel
Vegetarian eating
Other
syndrome
____________
Please expand in as much detail as possible:
______________________________________________________________________________
______________________________________________________________________________