NUTRITION CONSULTATION INTAKE FORM
Date: 10/27/2014
Patient Last Name: Lok
Date of Birth 1/22/1989
First Name
Street Address 505 beacon street unit 11
City
boston
State
ma
Home Phone
Work Phone
6177554439
Email Address anitaklok@gmail.com
Anita
M.I. K
Male/Female
Zip Code 02215
Cell Phone
REASON FOR YOUR VISIT
Did your doctor or another health care professional recommend you for a nutrition
consultation? yes
If not, who recommended you?
What is/are your reason(s) for obtaining a nutrition consultation?
Determine proper intake of food/water based
What do you hope to learn from your nutrition consultation(s)?
Determine proper intake of food/water based
MEDICAL HISTORY
Name of Primary Care Physician: Dr. Nasseh
617-414-5951
When was your last visit with your primary care physician? May 2014
Phone
When was your last dental visit? October 2014
Do you have any medical conditions (e.g. diabetes, high blood pressure, high
cholesterol)? Yes
No
If yes, please list:
Have you been hospitalized (medical, psychiatric, substance abuse, etc.)? Yes
If yes, please list reason(s) for hospitalization(s) and date(s).
No
Do you smoke? Yes No
If yes, number of cigarettes/packs per day and for how long:
Do you drink? Yes
No
If yes, please list the number of drinks per week.
Do you use any drugs or take prescriptions not prescribed for you? If yes, please list
How often do you exercise and what type(s) of exercise do you do?
6 times a week, heavy weightlifting and cardio
Do you play sports? Yes
No
If yes, please list:
FAMILY MEDICAL HISTORY
Please circle conditions that apply to you and or your family members.)
Overweight
Eating Disorders
Irritable Bowel Syndrome
Chron’s Disease
Heat Disease
High Cholesterol
Diabetes Type 1
Cancer (If so, what type(s)?)
Underweight
Food Allergies
Celiac Disease
Ulcerative Colitis
High Blood Pressure
Food Allergies (Type(s):
Diabetes Type 2
Other:
MEDICATIONS
Are you currently taking any medications? If yes, please list: birth control
Are you currently taking any vitamin/mineral supplements? If yes, please list: fish oil,
multi vitamin,
Are you taking any other types of supplements (herbal, sports supplements, etc.)?
If yes, please list:
garcinia, caffeine, BCAA, whey protein
ALLERGIES
Do you have any food allergies or intolerances (e.g. lactose intolerance)?
If yes, please list:
no
Do you have any environmental allergies? If yes, please list:
SOCIAL HISTORY
Single
Married
Occupation or year in school: professional
Living situation:
rent, alone
Favorite hobbies/activities? Exercising, shopping
Divorced
ADDITIONAL INFORMATION
Is there any other information you would like your nutritionist to know?
Signature
Date