Patient Information
Name:
Date of birth:
Local Address:
Home Address:
Please circle: Undergraduate or Graduate
Year of graduation:
Major:
Email:
Height:
Phone:
Weight (estimate/actual?):
Desired weight:
Wellness Screening — please circle responses
During the PAST 2 WEEKS, have you…
a. Been bothered by little interest or pleasure in doing things?
b. Felt down, depressed or hopeless?
YES
NO
YES
NO
c. Had 4 or more drinks containing alcohol, in a row, on at least one occasion? YES
NO
d. Consumed alcohol 3 or more days per week?
NO
YES
On how many occasions in the PAST 12 MONTHS have you used drugs** not prescribed to you?
No occasion
1-2 occasions
3-5 occasions
6-9 occasions
10-19 occasions
20-39 occasions
40 or more occasions
**Please note that “drug” refers to the use of prescription drugs not prescribed to you, or the
use of prescription drugs in a manner not intended by the prescribing clinician, or the use of
other drugs such as marijuana, cocaine, LSD, ecstasy, heroin or inhalants.
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Do you use tobacco?
Do you use marijuana?
If yes, indicate the number of each per day or week:
Are you thinking of quitting?
Number of hours of sleep per night:
Daily caffeine intake (number of cups per day):
Nutrition Intake
What are your goals, if any, for your nutrition appointment? Do you have any
specific questions or reasons for making the appointment?
When was your last physical/general wellness appointment?
Have you had any abnormal lab values (e.g. cholesterol, glucose) or other medical tests
(e.g. blood pressure, bone density)? If so, please indicate the lab values/tests and
dates:
Nutritionally speaking, what are your weaknesses/challenges?
Weight history (What is your usual body weight? Indicate your lowest and highest adult
weights with dates. Have you maintained or lost/gained weight in the past year? If so, was it
intentional or unintentional?):
What is your current method to maintain/gain/lose weight?
Current exercise regimen (aerobic and/or strength training; indicate how many sessions
per week, length of time of those sessions, intensity on a scale of 1-10 with 10 being the
highest):
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Exercise/athletics history:
Are there any physical limitations or past injuries that limit your ability to exercise?
Past medical history (including illnesses, fractures, surgeries, infections, diseases,
syndromes and/or disorders):
Have you ever been diagnosed or treated for disordered eating? (If yes, please
elaborate with dates/ages, hospitalizations, inpatient/outpatient programs, and treatments.)
Are any of your friends/family members concerned about the way you eat? If so,
why?
For women only: How old were you when you got your first period? Are your periods
regular?
Family’s (mother/father/siblings/grandparents) medical history (e.g. cancer, diabetes,
heart disease):
Are your family members able to maintain a healthy body weight or are they
underweight / overweight?
Prescription medications and reasons you are taking them:
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Vitamins / minerals / herbal supplements and reasons you are taking them:
Are you a vegetarian/vegan?
Are you following a specific diet at this time? If so, what?
Do you have any food allergies, intolerances, aversions or significant restrictions? Is
there anything you absolutely will not eat and why?
Do you have any ongoing gastrointestinal issues (chronic diarrhea/constipation/gas)?
How much water, juice, soda, coffee, tea, and other beverages (e.g. smoothies) do you
consume in a day? Please specify the daily quantity of each drink.
How many and what types of alcoholic drinks do you have per week?
What meal plan do you have for this academic year? What campus dining facility do
you use most often?
Recently, have you been restricting the amount of food you eat to influence your
shape or weight?
Are you preoccupied with the desire to be thinner?
Do you feel extremely guilty after over-eating?
Are you terrified of gaining weight?
Have you ever used or do you use laxatives or diuretics? For what reason?
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Have you attempted to follow a certain diet or rules regarding eating (e.g. a calorie
limit, specific foods, timing)? If so, please provide examples.
Do you binge with food and/or exercise?
Do boredom and/or stress affect your eating habits? How?
Have you ever kept a food journal for any reason? When and why?
If you are seeing any other medical clinicians or therapists, please list them here:
Who referred you to the dietitian?
*Please provide a separate food/fluid/exercise journal inclusive of at least 2 weekdays
and 1 weekend day before your appointment.*
Below is for the dietitian’s use only__________________________________________________________________
Actual wt: _______ lbs = _________ kg Ht: _______” = ____________ cm = __________________ m2
IBW: ___________ lbs = __________ kg
%IBW: ___________
Desired wt: _________ lbs = _________ kg
BMI: ____________ = ___________
Adjusted wt: ___________ lbs = ___________ kg
Hamwi method (_____ to _____ kcal/kg x ________ kg) = _________________________ kcal/day
Carbohydrates (50-60%) = _________________________ g carb/day
Protein (______ to ______ g pro/kg x ____________ kg) = ___________________ g pro/day
Fat (20-30%) = ___________________________________g fat/day
Fluid (35 mL/kg/d x ___________ kg) = ______________ mL (_______ cups/__________ oz)/day
Body Fat %: _____________%  _____________ lbs. fat  Category: ________________________________
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Mifflin-St.Jeor (REE x Activity Factor)
Men: 10(kg) + 6.25 (cm) - 5(age) + 5 = _____________ x AF _______ to ________ = ___________________
Women: 10(kg) + 6.25(cm) - 5(age) – 161 = ______________ x AF ______ to _______ =_______________
Activity Factors
1.2 – Sedentary / little exercise
1.3-1.375 – Mild activity (exercise 1-3x/week for 20+ minutes, or frequent long walks)
1.5-1.55 – Moderate activity (exercise 3-4x/week for 30-60 minutes)
1.7 – Heavy activity (exercise 5-7 days/week for 60+ minutes or construction/farming job)
1.9 – Extreme activity (relentless training schedule or very demanding job); rare
Handouts provided:
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