New Nutrition Patient Questionnaire:
Today’s Date:
*Please answer the questions to the best of your ability. The more information provided will enhance your experience.
Name: _____________________________________ Nickname:_________________________________
Date of Birth: _______ - ________ - ___________ Age: _________ Gender: ____Male ____Female
Marital Status: ____single ___married
Children: Y / N (list names & ages):_____________________________________________________________
Occupation:__________________________ Highest level of education:_______________________________
Please check all that apply: ___African American ___Native American ___Hispanic ___Caucasian ___Asian
___Pacific Islander ___Northern European __Mediterranean
___Other:__________________________________________
Primary Phone #: ________ - ________- ______________ ___Home ___Cell ___Work
Secondary Phone #: ________ - ________- ______________ ___Home ___Cell ___Work
Email address: _________________________________________________
Primary Physician: Name_________________________________ Phone #: ________ - ________- __________
Email: ______________________________________Practice Name:___________________________
Other Pertinent Provider: Name ___________________________Phone #: ________ - ________- _________
Email: ______________________________________Practice Name:___________________________
Do you see any providers in this clinic? Y / N, Name______________________________________________
Referred by: __________________________________________
Nutrition-Related Issues/Concerns:
Primary reason/s for your visit:_________________________________________________________________
Please list your top health/nutrition concerns:
1.
2.
3.
4.
5.
Describe any recent changes in your eating habits:
Have you ever met with a Registered Dietitian, Nutritionist, or Health Coach? Y / N
If yes, please provide name/date/reason for visit:
Oral Health:
Do you have any chewing problems? Y / N
If yes to either question, please describe:
Do you have any swallowing problems? Y / N
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
Allergy Information:
List IgE or immediate allergic reactions to any foods:_______________________________________________
List any food sensitivities or intolerances:________________________________________________________
List non-food allergic reactions (medications/environmental/etc.):____________________________________
Do you experience any unexplained allergy-type symptoms? Y / N
If yes, please explain:
Family Medical History:
Please note any family history of the following disease: heart disease, cancer, stroke, high blood pressure,
overweight/obesity, lung disease, kidney disease, diabetes, and/or mental illness
Family Member:
Health Condition:
Family Member:
Health Condition:
Family Member:
Health Condition:
Family Member:
Health Condition:
Medical History:
Please check health conditions that your doctor has diagnosed and provide date of onset.
GASTROINTESTINAL
__Irritable Bowel Syndrome
__Crohn’s Disease
__Inflammatory Bowel Disease
__Ulcerative Colitis
__Gastric or Peptic Ulcer Disease __SIBO
__GERD, heartburn
__Hepatitis or Liver Disease
RESPIRATORY
__Asthma
__Chronic Bronchitis
__Chronic Sinusitis
__Emphysema
__Pneumonia
__Tuberculosis
__Sleep Apnea
CARDIOVASCULAR
__Heart disease
__Irregular heart rate
__Stroke
__High blood pressure
__Elevated cholesterol
__Mitral valve prolapse
__High triglycerides
NEUROLOGICAL/BRAIN
__Depression
__Bipolar Disorder
__Anxiety
__ADD/ADHD
__Autism Spectrum
__Multiple Sclerosis
__Eating Disorder (type): __Migraine/Headache
__Seizures
__Parkinson’s Disease
DERMATOLOGICAL
__Eczema
__Skin rash
__Acne
__Psoriasis
__Rosacea
INFLAMMATORY/AUTOIMMUNE
__Celiac Disease
__Rheumatoid Arthritis
__Frequent Infections
__Severe Infectious Disease
__Herpes
__Gout
__Chronic Fatigue Syndrome __Lupus
MUSCULOSKELETAL/PAIN
__Osteoarthritis
__Fibromyalgia
__Chronic Pain
__Migraines
__Osteoporosis
__Osteopenia
CANCER
__Cancer (please describe type and treatment):
METABOLIC/ENDOCRINE
__Diabetes (type):
__Adrenal Fatigue
__Insulin resistance
__Pre-diabetes
__Hypoglycemia
__Hypothyroidism
__Hyperthyroidism
__Infertility
__Polycystic Ovarian Syndrome __Menopause
RENAL/GENITOURINARY
__Kidney stones
__Yeast infection
__Urinary tract infections
__Prostate problems
__Chronic Renal Failure
__Gout
Please describe any additional medical/health problems:____________________________________________
Please describe any previous surgeries (include the date):
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
Medication, Supplements, & Drugs:
Please list all prescription and OTC medications, supplements, herbs/botanicals you are currently taking.
*Use a separate sheet if needed.**Please bring in the bottles/labels to your appointment!**
Name & Brand Name
Dose
Frequency
Start date
Reason
Frequent antibiotics >3 times per year? Y / N
Long-term antibiotics? Y / N
Prolonged/regular use of pain relievers? Y / N
Prolonged/regular use of acid-blockers? Y / N
Recreational drug use: Y / N
Tobacco use: Y / N
Excessive caffeine intake: Y / N
If yes to above questions, please describe usual habit (i.e. amount, frequency, type, etc.):
Digestive Health:
How often do you have a bowel movement? __________ per ___day ___week
Describe your typical stool consistency: ___hard ___soft ___ loose __well-formed __alternate loose/hard
Please indicate the frequency and severity (1-10) of following symptoms:
Heartburn
Daily
Weekly
Monthly
Rarely
Never
Indigestion
Daily
Weekly
Monthly
Rarely
Never
Excessive Flatulence
Daily
Weekly
Monthly
Rarely
Never
Excessive Belching
Daily
Weekly
Monthly
Rarely
Never
Bloating
Daily
Weekly
Monthly
Rarely
Never
Stomach pain
Daily
Weekly
Monthly
Rarely
Never
Nausea/vomiting
Daily
Weekly
Monthly
Rarely
Never
Diarrhea
Daily
Weekly
Monthly
Rarely
Never
Constipation
Daily
Weekly
Monthly
Rarely
Never
Other:
Daily
Weekly
Monthly
Rarely
Never
Weight History:
Height:___________ Current Weight:_____________ When/Where were you last weighed?_______________
Highest Adult (>18years) wt:__________ date: __________ Lowest wt: ___________date:__________
List your GOAL wt:___________
Have you had any recent changes (+/- 10lbs) in your weight that you are concerned about? ___Yes ____No
If yes, please explain:________________________________________________________________________
Nutrition History:
Please describe any special diet or nutrition program you have used in the past:
___Commercialized weight loss program (i.e. Weight Watchers, Jenny Craig, Medifast, etc.)
Name of the program:________________________ dates:_______________ successful: Y / N / NA
Name of the program:________________________ dates:_______________ successful: Y / N / NA
Name of the program:________________________ dates:_______________ successful: Y / N / NA
__Vegan __Vegetarian __Pescatarian __Low OR high fat __Low OR high carb __Low OR high protein
__Gluten-free __Lactose-free __Dairy-free __Allergy-free __Detox program __South Beach __Atkins
__Paleo __Elimination diet __Ketogenic diet __Low-glycemic load __Anti-inflammatory diet
__Other (please specify):_____________________________________________________________________
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
Do you avoid any particular foods? Y / N ________________________________________________________
Do you crave any particular foods? Y/N _________________________________________________________
Have you ever had an eating disorder? Y / N _____________________________________________________
How many meals do you typically eat per day? ___________ # of snacks per day: __________
Dining out (fast-food, restaurant, cafeteria, snack bar, etc.)
Amount of meals:______________ per day / week (please circle one)
Typically consumed for: ___breakfast ___lunch ___dinner___ snack
Typical locations or cuisines:_____________________________________________________________
Do you consume alcohol? Y / N
If yes, please describe type, amount, and frequency:
Do you consume caffeinated beverages? Y / N
If yes, please describe type, amount, and frequency:
Do you use artificial sweeteners or “diet” products? Y / N
If yes, please describe type, amount, and frequency:
Please list the types of beverages you typically consume (type, amount, and frequency):
i.e. Milk (dairy and non-dairy), juice, soda, tea, coffee, diet drinks, sports beverages, smoothies, etc.
Do you identify with any of the following eating habits/issues? (check all that apply)
___late night eating __live/eat alone __over-sized portions __emotional/stress eating __skipping meals
__eating too quickly __yo-yo dieting __poor food choices __poor meal planning __erratic eating patterns
__overeating __binge eating __dislike healthy food __confused about healthy diet __crave carbs/sweets
__other:___________________________________________________________________________________
Who is the primary meal preparer for the household:______________________________________
Who is the primary grocery shopper for the household:____________________________________
List all members of the household:________________________________________________________
Usual grocery shopping locations: ___Whole Foods ___Trader Joe’s ___Farmer’s Markets ___Fresh Market
__Harris Teeter __Giant ___Food Lion ___Shoppers ___Safeway ___MOM’s ___Mars ___ Wegmans
___BJ’s ___Walmart ___Target ___Sam’s Club ___Other:_________________________
Are you willing to cook? Y / N
Please rate your cooking skills (1 (no skills) -10 (master chef)):__________
Please note any additional comments related to your nutrition/eating habits:
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
Food Frequency: Please indicate the approximate number of times you have eaten these foods in a typical week. For
each section you may cross out food/beverages seldom consumed, and circle foods/beverages you do eat.
Consumed in the past 7 days
Number
of Times
Number
of Times
Consumed in the past 7 days
Vegetables: Dark green leafy: spinach, Romaine,
leaf lettuce, Caesar Salad, etc.
Fish: (list):
fresh, fried or canned?
Iceberg lettuce or bagged salad combos, celery
cucumbers, zucchini
Broccoli, Brussels sprouts, cabbage/coleslaw,
kale, turnip or mustard greens
Fresh/frozen mixed veggies: corn, green beans,
peas
Yellow-orange veg: carrots, squash, sweet
potatoes
Tomatoes, pasta sauce, tomato juice, V-8, salsa,
etc
Fresh vegetable juices:
Other:
Poultry: Chicken: dark meat, breast
Turkey: dark meat, breast, lunch meat, turkey bacon
Beef: hamburgers, steak meatloaf, stew, chili
Is it usually regular, lean, grass fed or organic?
Fruits: (circle): banana, pear, apple, grapes, kiwi
Other:
Berries (list):
Canned/jar fruit: applesauce, pears, peaches
Pork: ham, sausage, bacon
Hot dogs: beef or turkey, bratwurst, italian sausage, etc.
Fried foods: fries, chicken, etc.
Lunchables®, bologna, salami, etc.
Vegetarian foods: (list):
Indian Vegetarian foods: (list):
Beans, legumes, peas: bean/lentil soup, bean burritos,
veg chili, split pea soup, etc.
Vegetarian foods: (list):
Veggie burgers, TVP, tofu, tempeh, seitan,
Quorn® products, etc.
Dried fruits:
Raw nuts/seeds: almonds, sunflower seeds, pecans,
walnuts, etc.
Wheat bread: rolls, buns, sandwiches, pita, bagel
White, whole grain, low carb, spelt, Ezekiel®
Cold cereal (list):
Hot cereal (list):
Pancakes, waffles tortillas: corn or flour
Trail mix, roasted salted nuts
Muffins, donuts, sweet rolls, granola bars
Pretzels, crackers, etc.
Gluten-free foods:
Flax seed meal or flax oil, cod liver oil?
Butter:
ORGANIC?
Margarine: (list brand):
Rice:
Potatoes: mashed, boiled or bakes? Red or white?
Pasta: spaghetti, lasagna, macaroni, pasta salad,
etc.
Potato chips, Fritos®, Doritos®, Pringles®, etc.
Popcorn: prepackaged or homemade?
Eggs: whole or whites only?
Dairy: Cow's milk: skim, 2%, or whole?
ORGANIC?
Yogurt, cheese, nachos, cottage cheese
ORGANIC?
Pizza: sausage, peperoni, vegetable, etc.
Ice cream, frozen yogurt, shakes, malts, etc.
Soy milk, goat milk, rice milk, almond milk
Peanuts, peanut butter, almond butter, tahini, etc
Protein powders: soy, whey, egg or rice?
Protein: liquid (ready-to-drink)
Candy (list):
Pie, cake, cookies, other snacks (list):
Gum, breath mints: regular or sugarless?
Coffee/espresso drink? Regular or decaf? # of 8oz
cups?
Tea: black, green, white, herbal infusion.
Sugar or no/low calorie sweetener? (list):
Soda pop: regular or diet? (list):
Alcohol beverage: wine, beer, hard liquor
Circle other frequent foods: Frozen/microwave meals: Weight Watchers®, Lean Cuisine®, Healthy Choice®, Mexican
cuisine, Indian cuisine, Chinese/Thai, Vegetarian, Atkins®, Low carb, SlimFast®, etc.
Average daily water intake in 8 oz glasses (not counting soda pop or coffee):
Is it: tap water, filtered tap water, spring water, distilled, etc.?
1-2
3-4
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
5-6
7-8
9-10
Physical Activity:
Please describe your current physical activity-
What is your favorite way to be more active?
In the past, what types of exercise programs have you tried?
Do you have any physical limitations that impair your activity level? Y / N ___________________________
Stress/Sleep:
Please rate your stress level, on a scale of 1 (low) to 10 (high), for the follow stressors:
_____Work _____Family _____Social _____Finances ______Health______Other:_____________________
Describe how you typically cope with stress:
i.e. yoga, meditation, breathing, listen to music, eating, exercising, reading, talking to friends, sleeping, etc.
Average hours of sleep per night during the week: _____________ , weekend:_____________
Difficulty falling asleep? Y / N / sometimes
Difficulty staying asleep? Y / N / sometimes
Are you well rested upon waking? Y / N / sometimes
Do you wake throughout the night? Y / N / sometimes
Do you currently or in the past take any sleep aids? Y / N ___________________________________________
Rate your overall quality of sleep (1-10):________
Other:
Please describe your support system: ___________________________________________________________
On a scale of 1 (not at all helpful) to 10 (extremely helpful), rank the level of support provided towards
your health goals from your friends and family: _________
On a scale of 1(not willing) to 5(extremely willing), please rate your willingness to:
 Modify your diet
 Take nutritional supplements
 Keep a detailed food record
 Modify your lifestyle?
 Practice relaxation techniques?
 Engage in regular physical activity?
 Attend regular follow up sessions?
Note any additional comments/questions/concerns:
University of Maryland Faculty Physicians, INC – Integrative Medicine Practice
2200 Kernan Drive
2nd Floor North
Baltimore, MD 21207
410 448 6361
CIMClinicInfo@som.umaryland.edu
www.compmed.umm.edu
Integrative Medicine
No Show/Cancellation Policy
Effective: October 3rd, 2013
Background
When patients don’t show up or cancel on a same-day basis, we are unable
to make the appointment available to someone else. This has a negative
impact on our appointment availability, as well as what we have to charge
for services. So, like many practices, we have implemented a No Show/
Cancellation policy.
Policy
If you fail to notify the practice of your need to cancel or reschedule an
appointment, or if you fail to show up for a scheduled appointment, we will
charge you for the visit. We will use a schedule of charges that is based on
the usual charge for that visit type.
Expected Outcome
We hope not to need to impose any charges under this policy. We
understand that schedules change and there is a need to reschedule
appointments. We are asking for sufficient notice of that to allow us to
make the appointment available to another person.
Thank you for your attention to this policy change,
Administration
PRIMIER Nationwide Collaborative Study
(Patients Receiving Integrative Medicine Interventions Effectiveness Registry)
We’re inviting you to participate in a study
Why?
We are part of a national study of how integrative medicine affects physical and
emotional health for various types of health conditions. The information from this study
will help us learn, and will help you and your practitioner assess your progress and plan
future care.
Who can participate?
All patients at least 18 years old are invited to participate.
What will I have to do if I participate?
You will be asked to complete an online survey at home. This will happen now, in 2
months, 4 months, 6 months, 12 months, 18 months, and 24 months. The survey asks
questions about how you are feeling physically and emotionally. Each survey takes
about 15 to 20 minutes to finish.
What are the questions like?
Survey questions are easy to complete. There are 7 survey categories: pain, anxiety,
depression, fatigue, sleep, physical function, and social function.
What do I do to get more information?
Please talk with your practitioner, or call Research Coordinator Mei Zheng at 410 4486462, or email her at mzheng@som.umaryland.edu
What do I do to participate?
Access the following website: https://redcap.ric.einstein.yu.edu/PRIMIER. There you
will find information and a consent screen. If you consent, you will be prompted for your
first survey. At appropriate times thereafter, you will get an email requesting that you
again provide the survey information.
We are committed to learning about integrative medicine, and to using information
about how you are feeling to plan your care. Thank you for helping us!