Nutritional Consultation Patient Intake Form
In order to facilitate the greatest positive benefit from your Nutritional Consultation,
please complete all applicable questions fully and honestly.
2044 S. Stoughton Road
Madison, WI 53716
For questions call (608) 271-8009
Name __________________________________________
Date _______________
Date of Birth______________ Age ________ Sex: M / F
Address________________________________________________________________
City ___________________ State ______ Zip ______________
Phone number________________________________
Are you currently a patient receiving treatment at this office? If so, for what and by whom?
_____________________________________________________________________
_____________________________________________________________________
How did you hear about us? ______________________________________________
How did you hear about this service? What prompted you to make this appointment?
____________________________________________________________________________________________
____________________________________________________________________________________________
Goals
Mark your single highest priority goal for this appointment:
__Weight loss __Energy __Athletic performance __Control of health condition __Reduce pain __ Sleep better
Other _______________________________________
If your goal is weight loss, mark greatest motivators:
__Feel better __Look better __More energy __Family history prevention __Improve health condition
Other ________________________________________
Lifestyle
Morning Routine:
What time do you usually wake up? ______________
How much time do you give yourself before you have to leave the house? _________________
Do you watch the morning news? Yes / No
When do you normally have your first foods? _________________________
When do you normally have your first liquids? ________________________
Evening Routine:
What time do you normally get home from work? _____________
What time do you usually eat dinner? ______________
How much screen time (TV/computer/phone) do you get every night? _________________
Do you watch the 10 pm news? Yes / No
What other normal activities do you do in the evening: _______________________________________________
Do you exercise regularly? Yes / No
If so, how many times a week: 1x 2x 3x 4x or more
What time of day do you exercise: Morning Day Night Late Night
When you exercise, how long is each session? Less than 15 min, 15-30 min, more than 45 min
What type of exercise is it? ________________________________________________
How much/How often do you consume the following each week? (Never, 1-3 times, 3-7 times, more than 7 times)
Candy _____________
Cheese, milk, ice cream and other dairy products ________________
Cups of coffee containing caffeine ______
Cups of decaf coffee or tea ____________
Cups of tea containing caffeine _________
Diet soda ________________
Regular soda ________________
Salty foods ________________
White bread products (rolls/bagels/pasta) ________________
Sodas with caffeine ________________ Sodas without caffeine ______________
Are you on a special diet? Yes / No
If yes, circle any that apply:
ovo-lacto vegetarian gluten free diabetic vegan dairy free dairy restricted
other, please describe__________________________
Is there anything special about your diet that we should know? Yes / No
If yes, please explain: _________________________________________________________
___________________________________________________________________________
Past Medical History
Please circle any conditions which have or currently do apply to you. In the space to the right, list any treatments you
received:
Anemia
High blood fats (cholesterol, triglycerides)
Arthritis
High blood pressure (hypertension)
Asthma
Irritable bowel
Bronchitis
Kidney stones
Cancer
Mental illness (Depression, Anxiety, etc)
Chronic Fatigue Syndrome
Mononucleosis
Crohn’s Disease or Ulcerative Colitis
Pneumonia
Diabetes
Rheumatic fever
Emphysema
Sinusitis
Epilepsy, convulsions, or seizures
Sleep apnea
Gallstones Gout
Stroke
Heart attack/Angina heart failure
Thyroid disease
Hepatitis
Other (describe)
Past Surgical History
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Family History
Please indicate relatives who had these conditions, and at what age:
Arthritis
Heart problems
Cancer
High blood pressure
Crohn’s Disease/ Ulcerative Colitis
High cholesterol
Diabetes
Kidney problems
Gallstones
Stroke
Thyroid disease
Recent Symptoms
Please circle any conditions which have or currently do apply to you:
GENERAL:
HEAD, EYES & EARS:
MUSCULOSKELETAL:
Cold hands & feet
Conjunctivitis
Back muscle spasm
Cold intolerance
Distorted sense of smell
Calf cramps
Daytime sleepiness
Distorted taste
Chest tightness
Difficulty falling asleep
Ear fullness
Foot cramps
Early waking
Ear noises
Joint deformity
Fatigue Fever
Ear pain
Joint pain
Flushing
Ear ringing/buzzing
Joint redness
Heat intolerance
Eye crusting
Joint stiffness
Night waking
Eye pain
Muscle pain
Nightmares
Headache
Muscle spasms
No dream recall
Hearing loss
Muscle stiffness
Unintentional weight loss
Hearing problems
Muscle twitches: Around
Unintentional weight gain
Lid margin redness
eyes Arms or legs
Migraine Sensitivity
Muscle weakness
Vision problems
Neck muscle spasm
Tendonitis
Tension headache
TMJ problems
DIGESTION:
Can't lose weight
Carbohydrate craving
Carbohydrate intolerance
Poor appetite
Salt craving
Bleeding gums
Bloating
Blood in stools
Burping
Canker sores
Cold sores
Constipation
Cracking at corner of lips
Dentures w/poor chewing
Diarrhea
Difficulty swallowing
Dry mouth
Gas
Heartburn
Hemorrhoids
Intolerance to:
Lactose All
milk products
Gluten (wheat)
Corn
Eggs
Fatty foods
Do you feel worse when you eat a lot of:
o High fat foods
o Refined sugar (junk food)
o High protein foods
o Fried foods
o High carbohydrate foods
o 1 or 2 alcoholic drinks
o Other __________________________
Do you feel better when you eat a lot of:
o High fat foods
o Refined sugar (junk food)
o High protein foods
o Fried foods
o High carbohydrate foods
o 1 or 2 alcoholic drinks
o Other__________________________
Medications and Supplements
What medications are you taking now? Include non-prescription drugs.
Medication name, Date started, Dosage
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
5. ____________________________________________________________________
6. ____________________________________________________________________
Are you allergic to any medications? Yes / No
If yes, please list medication and reaction:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
List all vitamins, minerals, and other nutritional supplements that you are taking now.
Indicate mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.
Vitamin/Mineral/Supplement name, Date started, Dosage
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________
4. _____________________________________________________________________
5. _____________________________________________________________________
6. _____________________________________________________________________
7. _____________________________________________________________________
8. _____________________________________________________________________