"Client Nutrition Assessment Form - Central Oregon Nutrition Consultants"

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Download "Client Nutrition Assessment Form - Central Oregon Nutrition Consultants"

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Lori S. Brizee MS, RD, LD, CSP
Central Oregon Nutrition Consultants
61456 Elder Ridge St, Bend, OR 97702
Home/office: 541-388-0694/Cell: 541-788-2625
lbrizee@bendbroadband.com
website:
www.centraloregonnutrition.com
Client Health and Lifestyle Questionnaire
Date __________
Name_____________________________________________________________________
Phone___________________________________ Cell phone________________________
Address ____________________________________________________________________
E-mail ______________________________________________________________________
Date of birth________
Age______ Occupation ___________________________________
Weight__________ Height ________(BMI____________) Goal Weight _______________
Why do you want to be at this weight? ________________________________________
Your weight at ages: 18 -25 years:________ 30-35 years: _______ 40-45 years __________
50-55 years_____ 60-65 years _____ 70+ years _____
Weight changes over last 5 years: ___________________ Weight 1 year ago ________
Physician __________________________Most recent physical examination ____________
General Health: Excellent
Good
Fair
Poor
Health Concerns: ___________________________________________________________
___________________________________________________________________________
Health History
Have you had or do you have any of the following health issues:
Respiratory
Aching muscles/joints
Eating disorder (binge
Asthma
Arthritis
eating/bulimia/anorexia)
Snoring
Back pain
Chronic headache/migraine
Sleep apnea
Skin and Hair
List any serious illnesses or
Cardiovascular
Rashes/dermatitis
medical conditions you have
Hypertension
Skin irritations
had:
Heart abnormality
Endocrine
__________________________
Heart attack
High chol/triglycerides
__________________________
Gastrointestinal
Thyroid abnormality
__________________________
__________________________
Diarrhea
Abnormal blood glucose
Constipation
Diabetes
__________________________
GERD
Depression
_________________
Abdominal pain
ADD/ADHD
Musculoskeletal
Anxiety
Stress level: low, moderate, high; Stressors: ______________________________________
Tobacco use: yes or no Alcohol: drinks per week? _________
Lori S. Brizee MS, RD, LD, CSP
Central Oregon Nutrition Consultants
61456 Elder Ridge St, Bend, OR 97702
Home/office: 541-388-0694/Cell: 541-788-2625
lbrizee@bendbroadband.com
website:
www.centraloregonnutrition.com
Client Health and Lifestyle Questionnaire
Date __________
Name_____________________________________________________________________
Phone___________________________________ Cell phone________________________
Address ____________________________________________________________________
E-mail ______________________________________________________________________
Date of birth________
Age______ Occupation ___________________________________
Weight__________ Height ________(BMI____________) Goal Weight _______________
Why do you want to be at this weight? ________________________________________
Your weight at ages: 18 -25 years:________ 30-35 years: _______ 40-45 years __________
50-55 years_____ 60-65 years _____ 70+ years _____
Weight changes over last 5 years: ___________________ Weight 1 year ago ________
Physician __________________________Most recent physical examination ____________
General Health: Excellent
Good
Fair
Poor
Health Concerns: ___________________________________________________________
___________________________________________________________________________
Health History
Have you had or do you have any of the following health issues:
Respiratory
Aching muscles/joints
Eating disorder (binge
Asthma
Arthritis
eating/bulimia/anorexia)
Snoring
Back pain
Chronic headache/migraine
Sleep apnea
Skin and Hair
List any serious illnesses or
Cardiovascular
Rashes/dermatitis
medical conditions you have
Hypertension
Skin irritations
had:
Heart abnormality
Endocrine
__________________________
Heart attack
High chol/triglycerides
__________________________
Gastrointestinal
Thyroid abnormality
__________________________
__________________________
Diarrhea
Abnormal blood glucose
Constipation
Diabetes
__________________________
GERD
Depression
_________________
Abdominal pain
ADD/ADHD
Musculoskeletal
Anxiety
Stress level: low, moderate, high; Stressors: ______________________________________
Tobacco use: yes or no Alcohol: drinks per week? _________
Sleep: Hours/night __________ Any difficulties? __________________________________
Medications: ________________________________________________________________
___________________________________________________________________________
Nutritional supplements (vitamins, minerals, herbs, type and brand)
___________________________________________________________________________
____________________________________________________________________________________
Nutrition Concerns: __________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
Previous nutrition or weight management programs
(what did you work on, and was it successful?)
____________________________________________________________________________
____________________________________________________________________________
Physical activity and/or exercise: Minutes
day _________ Days/week ________________
/
Types of Activities (e.g., walking, yard work, dancing, swimming, biking, etc): _____________
____________________________________________________________________________
Food Allergies: _______________________________________________________________
____________________________________________________________________________
Typical Eating Pattern:
Morning______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Mid Morning __________________________________________________________________
____________________________________________________________________________
Mid-day______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Mid afternoon _________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Evening _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Late Evening: _________________________________________________________________
_____________________________________________________________________________________
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