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HealthWise Nutrition Consulting

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home
Services
FAQ
Blog
About Us

Name

Gender

M F

Age

DOB

Wha are your resons for seeking dietitian/nutrition services?

Have you see an RD before?

Yes No

Have you see an RD before?

How tall are you?

What is your current weight?

When was the last time you weighed yourself?

How long have you been at this weight?

Do you follow a specific type of diet?

Do you have any food allergies o food intoleances?

Yes No

Do you have any food allergies o food intoleances?

Are there any foods that you avoid and / or self-restrict?

Yes No

Are there any foods that you avoid and / or self-restrict?

How is your appetite usually?

Excellent Good Fair Poor

Indicate which meals / snacks you typically eat daily:

Breakfast Lunch Dinner Snack 1 Snack 2 Snack 3 Other

How often do you eat out or buy take-out?:

Per week per month

Where do you lunch out or dine out?

Cafeteria Friend's home Restaurant Other

Do you receive meal delivery?

Yes No

Do you receive meal delivery?

Who does the grocery shipping in your home?

List a few of your favorite foods

Who does the cooking in your home? [ If someone else, it is beneficial ti have them on the call with the RD. ]

Spouse Other family member Self

Do you consume prepackaged/ canned/ fast foods? please explain, and how often?

Yes No

Do you consume prepackaged/ canned/ fast foods? please explain, and how often?

How many times a day do you eat the following?

Do you add salt to your food during cooking or at the table?

Yes No

Do you add sugar or arftificial sweetener to any food or beverage?

Yes No

How many cups or liters or ounces of water do you drink daily?

How many hours on average do you sleep at night?

How physically avtive are you?

Do you take dietary supplements?

Yes No

Do you take dietary supplements?

Do you have care giver support/ family support/ friend's support?

Yes No

Do you have care giver support/ family support/ friend's support?

would you like any one support member to be present for your cosult?

Yes No

would you like any one support member to be present for your cosult?

HealthWise Nutrition Consulting

We have been the most trusted Health Nutrition Consulting Service for over 10 years. We’re proud to offer nutrition education, counseling, and lifestyle coaching for chronic health conditions and overall healthy living.

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925-325-0119

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HealthWise Nutrition Consulting

HealthWise Nutrition Consulting

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