Daniella Wolf, BASc. RD
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Office Use only.
Consulting Dietitian and Nutritionist
NUTRITION PROFILE .
Patient History
Name: _______________________________________
Date of Consultation: ________________________________
Address: _____________________________________
Family Doctor: ____________________________________
street
______________________________________
city
province
Letter to Doctor:

postal code
Phone: (H) ________________ (W) _______________
Address: __________________________________________
Birthdate: ____________________________________
Phone: ___________________________________________
Occupation: __________________________________
Referred by: _______________________________________
Reason For Referral: ___________________________
Medical Conditions: ________________________________
Additional Information: _________________________
Date of last physical exam: ___________________________
Lab Data: ____________________________________
Medications: ______________________________________
Height: ____cm (____in.) Weight: ____kg (____lb.) BMI: ____WC*: ____
Goal: Weight: ____kg (___lb.) BMI:_____
Weight Change History: _______________________________________________________________________________
Physical Activity: ____________________________________________________________________________________
Food Allergies/Intolerances/Dislikes: ____________________________________________________________________
Vitamin/Mineral Supplements: __________________________________________________________________________
Factors Affecting Food Intake: ___________________
Recent Changes In Food Habits: _______________________
Meal Preparation: _____________________________
Meals Eaten Out:
Lunch ______
Dinner______
Food Frequency:
Milk Products:
skim 1% 2% soy
cheese ______________
yogurt ______________
frozen yogurt ________
ice cream ___________
Grains:
cereal __________________
bread __________________
rice ___________________
potatoes ________________
pasta __________________
Meat/Alternatives:
chicken ________________
fish ___________________
beef ___________________
pork __________________
legumes _______________
eggs __________________
lamb __________________
cottage cheese __________
tofu __________________
nuts __________________
Fruit:
juice _______________
fresh _______________
Vegetables:
salads __________________
cooked _________________
Fats:
butter _________________
margarine ______________
peanut butter ____________
oil ____________________
salad dressing ___________
mayonnaise ____________
Liquids:
coffee/tea ___________
soft drinks ______________
wine/beer/alcohol _____________
water _______________________
Sweets/Snacks:
_________________________________________________
One-Day Food Recall:
Breakfast:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Lunch:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Dinner:
____________________________
____________________________
____________________________
____________________________
____________________________
Snack:
Snack:
Snack:
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Initial Suggestions:
Food Recall Analysis
1.__________________________ 4. __________________________
Calories __________ Fibre _______________
2.__________________________ 5. __________________________
Carbs ____________ Unsaturated Fat ______
3.__________________________ 6. __________________________
Saturated Fat ______ Calcium ____________
Protein ___________
Nutritional Diagnostic Statements:
1. _______________________________________
4. _______________________________________
2. _______________________________________
5. _______________________________________
3. _______________________________________
6. _______________________________________
Diet Provided:______________________________________________________________________________
Educational Materials: WCFG
HLP
GHEG
Sample Food Plan
Other______________________
Food Plan:
Calories: ______________________
Protein:__________ g _________ %
Food Group
Svgs
Fat: ______ g ______%
Carbohydrates:______ g _______%
Date
Meat & Alt
Grains
Milk Products
Fruit
Vegetables
Fats
Dietitian's Signature: ________________________
Completion Date: __________________________
*WC waist circumference M<102cm/40in F<88cm/35in