Nutrition Assessment Form:
Name:
Height:
Age:
Current weight:
Profession:
Usual weight:
Desirable weight:
1) What is your main reason for this consultation? (Please circle/highlight): Weight Loss / Increase Energy /
Better Health / Sports Enhancement / Disease Prevention / Weight Gain / Other:
2) Have you experienced a recent weight gain? Yes  No 
or recent weight loss? Yes  No 
If yes, please explain:
3) Do you have problems with diarrhea, constipation, heartburn, nausea or vomiting? Yes  No 
If yes, please explain:
4) Do you have any food allergies or intolerances? Yes  No 
If yes, please explain:
5) List all regularly taken medications, vitamins, supplements (include protein powders, teas, shakes, etc.):
6) List any medical issues you would like me to be aware of (i.e. high blood pressure, cholesterol, IBS, etc):
7) Please list any psychological issues diagnosis (i.e. depression, anxiety, type of eating disorder):
8) Describe your current physical activity routine, as well as any physical limitations or injuries?
© Kim Denkhaus Nutrition. All Rights Reserved.
Kim Denkhaus, MS, RD, LD
424 234 3365
KimDenkhaus@gmail.com
How often do you do these? (amount of time/days per week, also try to give speed of machines/intensity
level to help better determine how many calories burned on a weekly basis from exercise):
9) How many times a week do you eat out or order take-out?
10) What are your nutrition questions or concerns?
11) What do you hope to take away from this session?
Food Journal
List all foods and beverages you consume on a typical weekday and weekend day.
Please complete all categories, and be as specific as possible.
DAY, TIME, ACTIVITY
FOOD/BEVERAGE
(include condiments, butter,
AMOUNT
DESCIRPTION
(Tbsp., cup, ounces, etc.)
(brand name, preparation
method, low fat, etc.)
Ex: Chicken breast, size of fist
Ex: 4 ounces
Ex: Fage 2% Greek Yogurt
Ex: Kashi GoLean Crunch
dressings, drinks, supplements,
etc.)
Ex: Monday
6:30am walk dog, answer emails
7:30am coffee with toast
Ex: Oatmeal
Ex: Coffee
© Kim Denkhaus Nutrition. All Rights Reserved.
Kim Denkhaus, MS, RD, LD
424 234 3365
KimDenkhaus@gmail.com
Informed Consent Regarding Electronic Communication & Internet Use of PHI:
Kim Denkhaus Nutrition encourages the opportunity to communicate electronically.
Transmitting PHI electronically possesses additional risks that Kim Denkhaus Nutrition would
like you to read and acknowledge.
Risks:
1) E-mail and teleconferencing can be immediately broadcast worldwide and be received
by intended and unintended recipients.
© Kim Denkhaus Nutrition. All Rights Reserved.
Kim Denkhaus, MS, RD, LD
424 234 3365
KimDenkhaus@gmail.com
2) Transmission of PHI can be disrupted or distorted by technical failures and/or the
transmission of the PHI could be intercepted.
It is the policy of Kim Denkhaus Nutrition that all electronic messages sent, or received,
which concern the diagnosis, or treatment, of the client will be part of the client’s PHI and will
treat such email correspondence, or internet communications, with the same degree of
confidentiality as afforded other portions of the PHI. Telecommunications will not be
recorded or stored. Kim Denkhaus Nutrition may forward e-mail messages within the entity as
necessary. Kim Denkhaus Nutrition will use reasonable means to protect the security and
confidentiality of e-mail, and internet communication, but because of the risks above, Kim
Denkhaus Nutrition cannot however guarantee the security and confidentiality of email, fax or
internet communications.
If consent is authorized, it is the responsibility of the client to use a protected
communication method, inform Kim Denkhaus Nutrition in writing of any type of information
you do not want to be transmitted, but not limited to such as diagnosis or treatment of
AIDS/HIV infection, other sexually transmissible, or communicable diseases, behavioral health,
mental health, or alcohol and drug abuse.
Kim Denkhaus Nutrition is not liable for breaches of confidentiality caused by the client.
Any further use of electronic communication initiated by the client constitutes informed
consent. I understand that the use of electronic communication may be withdrawn at any
time by written communication.
Patient Agreement & Cancellation Policy:
1) I agree that all the information presented here is truthful to the best of my
knowledge.
2) All scheduled appointments must be paid in full. Forms of payment accepted include:
Paypal, cash, check, credit card.
3) I agree to a 24-hour cancellation policy (by phone or email to 424-234-3365 or
KimDenkhaus@gmail.com) otherwise I will be billed for the full amount of the
consultation.
Please sign & date below:
(Signature)
© Kim Denkhaus Nutrition. All Rights Reserved.
KimDenkhaus@gmail.com
(Date)
Kim Denkhaus, MS, RD, LD
424 234 3365
Thank you, and I am committed to make my best effort to help you achieve your personal
health goals.
Look forward to working together!
© Kim Denkhaus Nutrition. All Rights Reserved.
KimDenkhaus@gmail.com
Kim Denkhaus, MS, RD, LD
424 234 3365