Personal and Lifestyle History

Personal History

Have you ever seen a nutritionist or dietitian?
Do you live alone?
Do you grocery shop?
Do you cook?
Do you have food allergies?
Do you smoke?
Do you vape?
Do you take street drugs?
Do you drink alcoholic drinks?
What meals do you mostly eat out?
What social media platforms do you use?
Sleep History
I recharge by:
When I am stressed, I crave:
How would you describe yourself?

Family History

Family History
Select any relevant family history
For any selected above, please list the affected family members and any other relevant information

Females Specific

MM slash DD slash YYYY
Are you on birth control?

Weight History

MM slash DD slash YYYY
MM slash DD slash YYYY
ex. thin/stocky as a child

Nutrition History

Religious or cultural food restrictions
Vegetarian, vegan, gluten-free, avoiding red meat, etc
Diabetic, low sodium, etc.
Do you count:

24 hours recall

Write the time, and what you ate yesterday or on a typical day
Do you have financial constraints surrounding food?