Medical and Nutrition History Form
Ruth Harper, MS, RD, LD
Name:
Date:
Age:
Date of Birth:
Best phone #:
Home address:
Insurance company and product (if seeking to make a claim):
Insurance ID number:
Reason for your visit:
Number of people living in your household:
Number of children 18 and under:
Marital status:
Mark any health issues that apply:
Diabetes
Irritable Bowel Syndrome
Polycystic Ovarian Disease
Kidney Disease
Diverticulitis
Food Allergies
Heart Disease
Gastric Reflux (GERD)
Overweight/Obesity
High Cholesterol/ Triglycerides
Chronic headaches/ Migraine
Constipation
High Blood Pressure
Thyroid Disease
Diarrhea
Cancer
Eating Disorder
Colitis
Sleep Apnea
Liver Disease
Celiac Disease
Depression
Anxiety
Crohn’s Disease
Other health issues not mentioned above:
Family History of above conditions:
Current Medications (and dosage):
Vitamin/Mineral/Herbal Supplements you take currently (and dosage):
Vitamin/Mineral/Herbal Supplements you are considering taking:
Smoker? Yes
No
If yes, how much:
Most Recent Lab Data: Date:
Cholesterol
LDL
Fasting Blood Sugar
Height:
Weight:
HDL
TG
Hemoglobin A1c
Blood Pressure
Desired Weight:
Highest Adult Weight:
When did you weigh this?:
Lowest Adult Weight:
When did you weigh this?:
Have you lost or gained weight recently?
If yes, explain:
Yes
No
Realistic Goal Weight:
Nutrition and Exercise Habits:
What is your previous diet experience? (Diets you have tried and results):
Are you “on a diet” right now? Yes
No
How much alcohol do you drink/ day?
If yes, please describe:
Per week?
Do you have any religious/cultural factors affecting your diet?
How many times do you eat out per week?
How many home cooked meals do you eat per week?
Who does the grocery shopping?
Carry out?
Who does the cooking?
How often do you skip a meal? Everyday
Most days
Some days
Rarely or never
What exercise do you engage in?
How often?
Do you enjoy exercise? Yes
Duration of exercise:
No
On a scale of 1 to 10, how motivated are you to make real changes your eating habits?
What motivates you?
On a scale of 1 to 10, how confident are you?
What foods do you love?
What foods do you dislike?
Would you say that food dominates your life? Yes
No
Food Recall: What have you eaten in the last 24 hours? Or, what do you eat on a “typical” day? Please include
approximate times of day.
Breakfast:
Snack:
Lunch:
Snack:
Dinner:
Snack:
Is there anything else I should know about you before we meet?: