Pelican Bay Nutrition
Nutrition and Health History
Name:_______________________________________
Age: _______
Gender:_____
Date:______________
Height: ________ Weight:_____________
Has your weight changed in the past 5 years?
Yes or No
(if yes please explain)
________________________________________________________________________
________________________________________________________________________
Medical History (Check any that apply)
sterol
Surgeries
Other_______________
____________________
____________________
Please list all medications:
________________________________________________________________________
________________________________________________________________________
Please list all nutritional supplements and meal replacements:
________________________________________________________________________
________________________________________________________________________
Do you exercise? Yes or No (If yes briefly describe your exercise program below)
________________________________________________________________________
_______________________________________________________________________
Do you smoke or use tobacco? Yes or No
tobacco cessation? Yes or No
Are you interested in information about
What prompted you to schedule a nutrition appointment?
__________________________________________________________________
What is the number one thing you would like covered in your appointment?
__________________________________________________________________
Please list 1-2 things you would like to change about your eating habits and briefly explain
why?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are you currently, or have you ever, been on a special meal plan or seen a Registered
Dietitian for nutrition counseling? Yes or No (if yes please explain)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Is it OK to contact you by phone and/or email? Yes or No
If yes, please provide contact info:
Phone: _______________________
Email: ________________________
I, ___________________________________, agree to allow Pelican Bay’s Registered
Dietitian, located at 8960 Hammock Oak Dr Naples Florida 34208 to provide nutrition
recommendations, wellness goals, and meal planning information with the intention of
enhancing my health and wellness. I understand that Pelican Bay’s Registered Dietitian
is not a physician and the information provided in our session is not to replace or
supersede the information provided to me by my health care practitioner or any member
of my primary healthcare team. I will be as honest as possible about my medical history,
medication, alcohol and drug use, exercise routine and current eating habits so that the
Registered Dietitian can provide the information that is best suited to meet my unique
nutrition needs. I will not hold Pelican Bay Foundation or the Registered Dietitian liable
for any problems, illness or injuries that may occur due to change in my eating or exercise
habits. I do hereby intend to be legally bound for myself and waive release of
any and all rights and claims for damages I may have against Pelican Bay Foundation
and the Registered Dietitian providing the nutrition consultation.
Signature:______________________________________ Date: __________________