Health And Wellness Intake Form
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1HEALTH AND WELLNESS INTAKE FORM
Past Health History
Have you seen a Registered Dietitian/Nutritionist before? ☐ Yes ☐ No If yes, please explain:
_____________________________________________________________________________________________
Please indicate if you have had a history of any of the following:
☐ Diabetes
☐ Atherosclerosis
☐ High Cholesterol
☐ Cancer
☐ Arthritis
☐ Pre-Diabetes
☐ IBS
☐ Eating Disorders
☐ Celiac Disease
☐ Heart Disease
☐ Anemia
☐ Fatigue
☐ Lactose
☐ Acid Reflux
☐ Diarrhea
Intolerance
☐ Constipation
☐ Thyroid Disorders ☐ High Blood
☐ Insomnia
☐ Other
Pressure
☐ Cancer. If yes, please indicate what type:
Please indicate if any member of your immediate family has had a history of any of the following
(please specify which member of your family)
Grandfather
Grandmother
Father
Mother
Brother
Sister
Diabetes/
Pre- Diabetes
Cancer
Heart Disease
Osteoporosis
Personal Health
How often do you exercise? ☐ ☐ Never
☐ ☐ 1-2 days/week ☐ ☐ 3-4 days/week
☐ ☐ 5-7 days/week
Please indicate if you are interested in any of the following:
☐ Gain weight
☐ Have more energy
☐ Exercise classes
☐ Lose weight
☐ Gain general nutrition knowledge
☐ Create an exercise program
☐ Eat healthier
☐ Treat a particular condition
☐ None
☐ Other, please describe: ___________________________________________________________________
Please let us know if there are any other health and wellness concerns or interests you may have:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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