Full Name

Date of Birth

Age

Address

City

State

Zip

Home Phone

Work Phone

Employer

Occupation

Emergency Contact

Name

Relationship

Address

City

State

Zip

Home Phone

Work Phone

List any and all allergies

Are you currently taking any medications?

Yes No

Medications

Medication 1

Dosage / Frequency

Condition

Medication 2

Dosage / Frequency

Condition

Medication 3

Dosage / Frequency

Condition

Are you under the care of a physician or other health professional?

Yes No

If yes, reason & provider name

Non-user or former user

Date quit

Cigar and/or pipe 15 or fewer cigarettes per day 16 – 25 cigarettes per day 26 – 35 cigarettes per day More than 35 cigarettes per day

Family History — check all that apply

Asthma

Respiratory / Pulmonary Conditions

Diabetes

Type I – Who

Type II – Who

How long?

Epilepsy

Osteoporosis

Are you following a specific food or diet plan?

Yes No

If yes, list plan and who prescribed it

Do you take dietary supplements?

Yes No

If yes, please list

Do you notice your weight fluctuating?

Yes No

Have you experienced a recent weight gain or loss?

Yes No

If yes, explain how

Over what time period

How many caffeinated beverages per day, and what are they?

How would you describe your current nutritional habits?

Other food or nutritional notes (allergies, mealtimes, etc.)

Work and Exercise Habits — select one

Intense occupational and recreational effort Moderate occupational and recreational effort Sedentary occupational and intense recreational effort Sedentary occupational and moderate recreational effort Sedentary occupational and light recreational effort Complete lack of activity

Work Stress Level

Minimal Moderate Average Extreme

Home Stress Level

Minimal Moderate Average Extreme

Do you work more than 40 hours per week?

Yes No

Anything else you would like your nutrition coach to know?

Printed Name

Date

Signature

Draw your signature using finger or stylus

Parent or Guardian Signature If participant is under 18

Draw signature using finger or stylus