Name *AgeOccupationWhat are you doing in life and are how do you feel about it?Who do you live with?Purpose of our Consult - Tell me about why we are meeting. * What do you feel is the primary purpose?Relevant Medical History- Please list/describe any medical diagnoses or procedures I should be aware of. *If applicable, have there been any inconsistencies with your menstrual cycle? *YesNoPlease describe. *Please list your current medications & supplement dosages: *Please list/describe any mental health concerns should I be aware of (i.e. depression, anxiety, OCD, PTSD). *Rate your current perceived level of stress on a scale of 1-10:12345678910Have you ever worked with a dietitian/nutritionist?YesNoTell me about your experience. *Digestive HealthHave you ever received a gastrointestinal (GI) diagnoses? *YesNoPlease Explain. *Did you have any GI issues as child or adolescent? *YesNoPlease Explain. *Do you have any food allergies or intolerances? *YesNoPlease Explain. *Gastrointestinal symptoms: On a scale of 1-10 (10 = terrible, 0=non-existent) please state a number that identifies the level intensity of the following symptoms:Gas012345678910Bloating012345678910Nausea012345678910Diarrhea012345678910Constipation012345678910Abdominal Pain012345678910Reflux/ (GERD)012345678910Incomplete Emptying012345678910Relevant Family HistoryShare with me any family dynamics you feel are important for me to know/understand.What was food like in your house growing up?What is it like now?Does anyone in your family have a history of dieting, disordered eating, or eating disorders? Other chronic illnesses?Food & Nutrition - Tell me about your dieting and/or your eating disorder history.Eating Patterns How many meals a day do you eat?Do you skip meals? If yes, which ones do you skip and why?What are your snacking habits (i.e. frequency, time of day, foods you choose)?When you feel overwhelmed or life gets busy, do you neglect your eating habits? If yes, please describe.Do you feel that your life/schedule conflicts with nourishing your body in the way you’d like to? If yes, please describe.Do you eat and multi-task (i.e. read, watch TV, drive)? If yes, please describe:Where do you eat your meals? Do you feel you eat particularly fast or slow? Please describe:Do you like to cook? Who does the grocery shopping? Who prepares the food at home?Please list the usual time and typical daily intake for each meal:BreakfastLunchDinnerSnacksWhat foods do you love?What foods do you hate?Are there any foods that you fear or feel like binge foods for you?Are there any foods that feel “safe” to you?Does your diet have a lot of variety or does it tend to be the same from day to day?Exercise and Activity Have you ever had a consistent exercise routine? If yes, tell me about your past exercise habits/relationship to exercise:Tell me about your current exercise habits/relationship to exercise:WeightYou can leave blank if you prefer or if it feels uncomfortable, we can discuss it in session together.HeightAverage WeightOver the past 2-3 years.Weight you feel most comfortable; When were you last at that weight?Highest adult weight? Age:Lowest adult weight? Age:If applicable, pre-pregnancy weight?How much weight did you gain with pregnancy?Have you lost or gained weight recently? How much? Time frame?Do you weigh yourself currently? If yes, how frequently:Please select how you currently feel about your body.Strongly DislikeDislikeSlightly SatisfiedSatisfiedVery SatisfiedWorking together What do you hope to accomplish through our visits together?Please feel free to share any additional information here.EmailSubmit