Nutrition Counseling Form

Date:

First & Last Name:

Time:

Choose a time

Referring Clinician:

Contact Information: Phone number

Contact Information: Email

Precounseling Food Log Submitted?

Reason(s) for Visit:

Goals:

Breakfast:

Lunch:

Dinner:

Snacks:

Beverages:

Allergies and Food Sensitivities:

Dietary Limitations (dislikes, cultural/religious/ethnic preferences):

Time/Prep Issues:

Sleep Patterns:

Stress/Enviromental Issues:

Weight History:

Do You Wear Any Fitness Trackers - Apple watch, Fitbit, Whoop, Oura?

Family Support:

Exercise Patterns (time, day, duration, type):

Sex:

Age:

Height (Feet & Inches):

Current Weight (lbs):

Peri/Post Menopause:

Med Hx:

Family Hx:

Medications, Supplements, OTC:

Do you know your Enneagram Number? If so, what is it?