Nutrition Therapy, LLC
Eileen F Pierro MED, RDN, LD
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Personal and Lifestyle History
Personal History
Name
Sex
Male
Female
Other
Occupation
Have you ever seen a nutritionist or dietitian?
Yes
No
If Yes, for what?
If Yes, for how long?
What worked in previous nutrition counseling?
What did not work in previous nutrition counseling?
Name of Dietitian:
Reason for discontinuing previous nutrition counseling?
What are your current beliefs and attitudes surrounding nutrition counseling?
Do you live alone?
Yes
No
If no, who do you live with?
Do you grocery shop?
Yes
No
If no, who does?
Do you cook?
Yes
No
Do you have food allergies?
Yes
No
If yes, what are your allergies?
Do you smoke?
Yes
No
If yes, how many cigarettes a day?
Do you vape?
Yes
No
If yes, how often daily?
Do you take street drugs?
Yes
No
If yes, what?
Do you drink alcoholic drinks?
Yes
No
If yes, what?
How many days a week do you drink alcohol?
How many days a week do you eat out?
What meals do you mostly eat out?
Breakfast
Lunch
Dinner
Social Network
What social media platforms do you use?
What is your daily routine?
Sleep History
I go to bed at the same time, and wake up at the same time daily
I follow a regular sleep schedule during weekdays but not weekends
I don't sleep well at night and take naps in the middle of the day
I recharge by:
exercising, socializing, cleaning
resting, reading, watching TV, driving
Meditation, prayer, spiritual practice
When I am stressed, I crave:
chocolate, candy, chips
caffeine, meat, or spicy foods
vegetables, whole grains, nuts
How would you describe yourself?
I worry I am not good enough
I'm lazy
It's hard to get going
I am ambitious
I feel worthy
I'm high energy
I'm active and restful
Relationships
I have a few relationships and I am often lonely
I have lots of friends I regularly meet with
I have few close relationships
Who do you live with?
Family History
Family History
Alcoholism
Arthritis
Asthma
Cancer
Depression
Thyroid Abnormalities
Diabetes
Digestive Problems
Eating disorder
Headaches
Heart Problems
High Blood Pressure
High Blood Sugar
High Cholesterol
Kidney disease
Obesity
Psychological Illness
Polycystic Ovarian
Substance abuse
Sleep apnea
Select any relevant family history
Please elaborate on family history
For any selected above, please list the affected family members and any other relevant information
Females Specific
Age of first menses
Date of your last menstrual period
MM slash DD slash YYYY
Have you missed your menses and for how long?
Days between periods
Days periods last
Are you on birth control?
Yes
No
Weight History
Height
Current Weight
Desired weight
Current BMI
What was your highest weight at your current height?
When were you this weight?
MM slash DD slash YYYY
What was your lowest weight at your current height?
When were you this weight?
MM slash DD slash YYYY
Usual body weight:
Growth history
ex. thin/stocky as a child
Expected weight for age?
Nutrition History
Do you have any food fears?
Religious or cultural food restrictions
Yes
No
If yes, what?
Self imposed diets?
Vegetarian, vegan, gluten-free, avoiding red meat, etc
Medically prescribed diets?
Diabetic, low sodium, etc.
Previous diets
Any recent changes in eating habits?
Do you count:
Calories
Carbohydrates
Fat
24 hours recall
Write the time, and what you ate yesterday or on a typical day
Breakfast
Lunch
Dinner
Snacks
Eating location/environment
Who did you eat with?
Do you have financial constraints surrounding food?
Yes
No
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Eileen Pierro, RD,LD
Nutrition Counseling
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