Patient's Full Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is patient a minor (under 18 years old)?
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Yes
No
Preferred Languages
English
Spanish
English & Spanish
Portuguese
German
Hindi
Gujarati
Legal Guardian Full Name
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First Name
Last Name
Relationship to patient
Parent
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Health Insurance
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Anthem & BCBS
AETNA
Meritain Health
Nippon
United HealthCare (UHC)
UMR
UHC - ALL SAVERS
UHC - GOLDEN RULE
Cigna
Humana
Kaiser Permanente
Multiplan
Optum Discount Plans
Private Payer
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Insurance ID#
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Referring Medical Professional (if any)
REASON for consulting a Registered Dietitian?
*
Nutrition education Healthy eating
Plant based diets/Vegetarian diets/ Vegan diets
Distorted/disordered eating patterns
Maternal Nutrition: pre/during and postpartum
Maternal Nutrition: Gestational Diabetes
Weight management (to reduce weight)
Unintentional weight loss or low body weight
Nutrition adequacy for chewing and swallowing problems
Nutrition adequacy of cardiovascular disease (high cholesterol, triglycerides, blood pressure, etc)
New onset of Diabetes Mellitus
New onset of type 1 Diabetes (usually w/INSULIN)
New onset of Celiac Disease
Altered Gastrointestinal functions (explain below)
Altered nutrition-related laboratories
Nutrition for Early stages of Kidney Disease
Nutrition for End-Stage of Kidney Disease
Nutrition Support for oncology pre/during and post treatments
Bioelectrical Impedance body Analyzer study (BIAS)
Genetic testing for Personalized Nutrition with FFQ: Nutrigenomix (Health&Wellness, Sport&Performance, Fertility and Plant-based testing)
Food Frequency Questionnaire (FFQ) Computerized for clients who want to evaluate food/nutrient intake related to recommendations
Other reasons, please explain
Please, explain any other reason not mentioned above
Preferred Locations
*
TELEHEALTH - Virtual Consulting
JOHNS CREEK - Medical Pavilion - 6300 Hospital Parkway Ste. 225, Johns Creek, GA 30097
LAWRENCEVILLE - Huntcrest Building - Not accepting new patients at this location
ATLANTA/BUCKHEAD - One Alliance Center - 3500 Lenox Rd, Suite 1500, Atlanta, GA 30326
How did you hear about NutritionECW LLC?
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Primary Physician
Insurance
Medical Referral
Family or Friend
Internet research
Media, TV, Magazine
Other
Other, Who?
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