Nutrition Counseling Registration Form - Adult Patient’s Name ______________________________________________________ Date_____________ Last
First
Middle
Mailing Address _______________________________________________________________________ Street
City
Zip Code
Phone (H) ___________________________________ (Cell) ____________________________________ Email Address ________________________________ Occupation _______________________________ Gender
Male
Female Birth date ______________________________Age ___________________
Health Insurance Company ___________________ Policy Holder’s Name _________________________ Policy Holder’s DOB _______________________ Policy Holder’s ID # _____________________________ Policy Holder’s Employer ________________________________________________________________ Policy Holder’s Group or FECA # ____________________________ Patient ID # ____________________ Medical Contact Physician’s Name _______________________________________________________ Physician’s Address _____________________________________________________________________ Physician’s Phone Number _______________________________________________________________ Medical History Height __________Weight __________ Recent Weight Change ___________________ Gain or Loss? How Much?
Are you currently being treated by a physician? If yes, please explain _____________________________ _____________________________________________________________________________________ Past Medical History - Do you have a history of any medical conditions? Food Allergies
Eating Disorders
GERD (Heartburn, Reflux) Kidney Disease
Arthritis
Endocrine Concerns
High Blood Pressure Osteoporosis
(Diabetes, Hypoglycemia, Thyroid)
Cancer
Gastrointestinal Concerns
High Blood Fats
Weight Concerns
(Constipation, Diarrhea, Nausea, Vomiting)
(Total Cholesterol, LDL, Triglyceride)
(Overweight, Underweight)
Other Nancy Z. Farrell, MS, RD 231 Park Hill Drive, Suite A, Fredericksburg, VA 22401 (540) 479-3404 Fax (540) 373-7008 www.farrelldietitian.com
Lab Results Cholesterol_____________ LDL_____________ HDL_____________ TG_____________ Blood Pressure__________ Blood Glucose__________ HbA1c__________ Other__________________
Medications Please list current prescription and non-prescription medicines, vitamins, minerals and herbal supplements. _____________________________________________________________________________________ _____________________________________________________________________________________
Nutrition What are your nutrition concerns or reasons for visit? Anemia
General Nutrition/Eating Better
Sports Nutrition
Diabetes
Gastrointestinal
Vegetarian Meal Planning
Eating Disorder
Heart Health
Weight Management
Other (specify) _____________________________________________________________________
Have you seen a Dietitian before? Yes or No If yes, please explain when and why? ____________________________________________________________________________________ How did you hear about Farrell Dietitian Services? ___________________________________________
Exercise Do you currently exercise? Yes or No If yes, what type of exercise? How many times per week? For what length of time (minutes)? _____________________________________________________________________________________ How long have you been on this exercise program? ___________________________________________ Do you have any condition that limits your physical activity? Yes or No Explain_______________________________________________________________________________
Nancy Z. Farrell, MS, RD 231 Park Hill Drive, Suite A, Fredericksburg, VA 22401 (540) 479-3404 Fax (540) 373-7008 www.farrelldietitian.com