Dietitian Appointment - New Patient Form
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1Dietitian Appointment – New Patient Form
To provide you with the best individualized nutrition care possible, please complete the following
questionnaire. Bring the completed form to your Dietitian visit.
PERSONAL INFORMATION
Name: _____________________________ Age: _______ Date of Birth: ____ _________
HEALTH INFORMATION
Height: _________
Current weight: _________ Usual weight: _________
Has your weight changed in the past year? □ yes □ no
If yes, please list: _________ pounds □ lost □ gained
Was this intentional? □ yes
□ no
Do you exercise? □ yes □ no
If yes, what type and how often? _________________
Are there any medical reasons you cannot or should not exercise? □ yes
□ no
If yes, please list: _______________________________________________________________
□ High
□ Moderate □ Low
□ None
Please rate your current stress level
What adds most to your stress? □ Family □ Money □ Health □ Work □ Other: ___
_______
NUTRITION INFORMATION
Have you met with a Registered Dietitian in the past? □ yes □ no
If yes, when/where? ___________________ ________________________
___
_____
Do you follow a special diet or eating style? □ yes □ no
If yes, please describe: ____________________________________________
__________
Please list any strong overall food preferences:
_____________________________________________________
____________________
Who does your grocery shopping? □ myself
□ other:________________________
Who prepares your meals? □ myself
□ other: ____________________________
How many meals do you typically eat each day? _____________
Do you ever skip meals? □ yes □ no
If yes, when/why?_____
______________ ______
How many meals per week do you typically eat away from home, and where? (for example: at your
workplace, restaurant, social event, etc.): _________
_______________________________
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Parent category: Medical