New Patient Form Step 1 of 7 14% Welcome to the road to better health; I am delighted to be on this journey with you! Here are a few details as we move toward your nutrition consultation: Please complete this form prior to your consultation, along with the other forms listed under Patient Forms. Please attempt to include one weekend and one week day in the food journal if possible. I am a Blue Cross, United Healthcare, Regence, and Medicare provider and will bill your insurance for you (please call your insurance prior to your appointment to check if dietary counseling is part of your specific plan). I offer a discounted rate for private pay which is $120 per hour, and is payable by cash, check, credit card, or health savings plan, and due at the conclusion of our appointment. For other insurances, upon request I can provide you a receipt to submit to your insurance provider for potential reimbursement. If you are a Medicare recipient, I will also have you sign an Advanced Beneficiary Notice (ABN) at the time of your appointment. This ensures that even if your diagnosis is not covered by Medicare, the claim can be submitted for payment to your secondary insurance. If you would like to read this form prior to your appointment, please click here. If you have any questions, feel free to contact me. I look forward to working with you!Patient InformationName* First Last Preferred NameDate of Birth* Age*Gender*MaleFemaleAddress* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Phone*Secondary PhoneEmail* Please mark all the ways that I may contact you:* Phone Email Text Is it OK to leave a phone message?*YesNoWhat is the best way to contact you?*PhoneEmailTextPrimary Physician and Other ProvidersClick "+" to add moreNamePhone Referred by (doctor's office, friend, website, etc.)*Insurance Provider (if applicable)Please call ahead for coverage of dietary counseling. If covered, please call your doctor's office and ask them to fax (888.972.6280) your "diagnosis code" to my office either as a referral or on letterhead. Provider NamePolicy Number Height*Current weight*Usual weight range*Desired weight (if applicable)Have you had any recent weight gain or loss?*YesNoPlease describe Health GoalsWhat do you hope to achieve with your appointment?*What are your main health/nutrition concerns?* When was the last time you felt well? And did something trigger your change in health?What makes you feel better?What makes you feel worse? Medical HistoryPlease check all health conditions that your doctor has diagnosed* Check here if none apply ADD/ADHD Anxiety Asthma Autism Celiac Disease Chronic Fatigue Syndrome Chronic Pain Chronic Sinusitis Crohn's Disease Depression Diabetes Eating Disorder Fibromyalgia GOUT Hashimoto's Syndrome Heart disease High Blood Pressure Hyperthyroidism Hypothyroidism Infertility Irritable Bowel Syndrome Kidney Stones Metabolic Syndrome Migraine Overweight Polycystic Ovarian Syndrome Reflux, Heartburn, GERD Rheumatoid Arthritis Skin Condition Stroke Underweight Ulcerative Colitis Yeast Infection Other GI Disorder Other Cardiovascular disorder Other Inflammatory Condition Other Autoimmune Disorder Any Other Disorders Please List Any Other Disorders:If you have received testing for the condition for which you are seeking nutrition counseling, please list the tests performed (blood work, procedures):Do you have a regular monthly menstrual cycle?*(women only)YesNoplease explain (such as “menopause”, etc.):Please list all prescription and non-prescription medications and/or nutritional supplements you are currently taking (write none if you are not taking anything)*(use "+" to add more)Medication/SupplementDoseFrequencyReason Have you had frequent use of antibiotics?*YesNoHave you used antibiotics in the last 5 years?*YesNoPlease describe any past surgeries that you have had Family HistoryPlease list any known family medical conditions such as heart disease, diabetes, overweight, underweight, allergies (both food and non-food), cancer, high-blood pressure, or any other potentially relevant condition.(click "+" to add more)Family memberCondition Genetic background: Caucasian Hispanic Native American Mediterranean African-American Northern European Asian Other Readiness AssessmentWhat do you think would make the most difference in your overall health?*In order to improve your health, how willing are you to:1 - Not Willing2345 - Very WillingSignificantly modify your dietEngage in regular physical activityModify your lifestyle (work demands, sleep, exercise)Keep a record of everything you eatPractice relaxation techniquesTake supplements for nutrition therapyHave a lab test performed for a health assessmentComments Lifestyle Information ExerciseDo you participate in moderate cardiovascular exercise (jogging, biking, hiking, brisk walking, etc.) for at a minimum duration of 20 minutes at least 3 times per week?*YesNoPlease list any activity in which you participate below.(click "+" to add more)ActivityType/Intensity (low-moderate-high)# Days Per WeekDuration (minutes) Do you have any issues that limit your physical activity? If yes, please explain:*SleepAverage # of hours you sleep per week night*Do you have trouble falling asleep?*YesNoAre you rested when you awaken?*YesNoDo you wake up during the night?*YesNohow many times on average?How would you rate your overall quality of sleep?*1 (Poor)2345 (Great)SocialDo you consider yourself spiritual?*YesNoWhat is your religion (optional)?Are you married?*YesNoDo you have children?*YesNoHow Many?Do you feel connected with others including family, friends and/or other social groups?*DefinitelySomewhat connectedI have limited connectionsI am not very connected to othersWhat is your occupation?*StressWould you say that your life is stressful?*YesNoMark all items that you experience: Weak all over Rapid, pounding heart Tightness in chest Feeling like you can’t breathe Dizziness and sweating Chronic fatigue Muscle aches, tension, tremors Confusion Hopelessness Extreme self-consciousness Feeling like you will faint Very fearful Anticipating tragedy Excessive worry Uneasiness Loneliness Isolation Depression Wanting to scream with anger Embarrassed, rejected, or criticized Please rate your daily stressors*1 - Low2345 - HighWorkFamilyFinancesHealthOtherOther daily stressors (please describe)How do you handle your stress? And do you feel that this is effective?*EnvironmentAre you regularly exposed to any chemicals/environmental pollutants including cigarette smoke, auto exhaust/fumes, dry cleaned clothing, hair dyes, heavy metals, aluminum cookware, paint fumes, mold, pesticides, or fertilizer?*YesNoIf yes, please list:What cleaning products do you use to clean your home?*What do you use to clean your clothes?*What do you use to clean your dishes?*Do you use chemicals on your lawn/garden?*YesNoDo you purchase mostly organic or conventionally grown food?*OrganicConventional Nutrition and Digestion InformationHave you ever had a nutrition consultation?*YesNoPlease explain the nature and the outcomeHave you made any changes in eating habits because of your health?*YesNoPlease describeDo you avoid any particular foods?*YesNoPlease describeDo you have any food allergies or adverse food reactions that you know of?*YesNoPlease list and explain symptoms you experienceDo you have any non-food allergies (seasonal, latex, medications, etc.)?*YesNoPlease list allergens and explain symptoms you experience (write none if this does not apply to you)*Do you have (or have you had) an eating disorder?*YesNoPlease describeFrequency of bowel movements*Do you smoke?*YesNoNumber of yearsNumber of packs per dayHow many meals do you eat per day?*How many snacks?*Approximately how many ounces of fluid do you drink per day (there are 8 oz. in a kitchen measuring cup)?*Approximately how many ounces of water do you drink per day?*Do you drink alcohol?*YesNoHow many drinks per week?Do you drink coffee or other caffeinated beverages?*YesNoWhat beverages and how many per day?*If you were limited to just a few foods that you could eat, what would they be?*Check all that apply Love to eat Love to cook Do not like to eat Do not like to cook/prepare food Limited cooking knowledge Do not plan meals Forget to eat Eat because I have to Dislike healthy food Negative relationship with food Eat in front of TV Fast eater Erratic eating patterns Eat too much/overeat Eat fast food frequently Travel frequently Late night eater Eat alone Emotional eater Confused about food/nutrition Family eats differently UntitledCommentsThis field is for validation purposes and should be left unchanged.