NUTRITION ASSESSMENT FORM

Weston Med Spa & Cosmetic Surgery

1601 Town Center Circle Suite A. Weston FL 33326 www.thetemple.healt
NUTRITION ASSESSMENT FORM
One's health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits.
Take a Picture of your InBody Test
Name and Last name*
Date of Birth*

MonthDayYear
Date
Gender

MFNB
Occupation
Marital status

PartneredMarriedSeparatedWidowedDivorcedSingle
Previous or referring doctor
Date of last physical exam

MonthDayYear
Date
List any medical problems that other doctors have diagnosed
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Please answer here
Excercise

Mild exercise (i.e., climb stairs, walk 3 blocks, golf)Occasional vigorous exercise i.e., work or recreation, less than 4x/week for 30 minRegular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)Sedentary (No Excersivce)
What kind of diet have you tried before?

No (Explain) Did you use supplement(s)? Have you tried appetite suppressors?Yes Which type?
If answered Yes. Please explain which appetite suppressors have you tried
No (Explain) Did you use supplement(s)? Have you tried appetite suppressors?

Yes NoHave you diet before? Did it work?Yes
Are you on a prescribed medical diet?
# of meals you eat in an average day?
What is the schedule for your meals? (Write an example day routine)
Do you cook?
Rank your Salt Intake
Oil Intake (Fat Types)
Common Allergies mark all that apply

GlutenPeanutFishEggsTree NutsSoyShellfishDairy
Caffeine Mark all that apply

NoneTeaCola
Do you dink Alcohol?*
If Replied "Yes" please specify which type
Do yo Smoke?*
If you replied "Yes". How many units per "day" and for how long
Do you currently use recreational or street drugs?*
Have you ever given yourself street drugs with a needle?
FAMILY HEALTH HISTORY
WOMEN ONLY
Date of last menstruation

MonthDayYear
Date
Period every
Number of pregnancies
Number of live births
Are you pregnant or breastfeeding?
Have you had a D&C, hysterectomy, or Cesarean?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritability, or othersymptoms at or around time of period?
Pregnant or Lactating?
MEN ONLY
Do you have any problems emptying your bladder completely?
Date of last prostate and rectal exam? (If you are older than 50 years old)

MonthDayYear
Date
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

SkinChest/HeartHead/NeckBackWeightEarsIntestinalEnergy levelNoseBladderAbility to sleepThroatBowelOther pain/discomfort:LungsCirculation
Please Briefly explain
ANTHROPOMETRIC MEASURES
Heigh (Feet)*
Height (Inches)*
Current Weight*
In LB
Activity Level
AUTHORIZATION FOR THE RELEASE OF INFORMATION
I, First Name* Last Name* , Hereby authorize the use or disclosure of my health information from the listed health care practitioner as described below to the requesting practitioner.
Authorization:

Yes, I AuthorizeNo, I do not Authorize
Please fill this form and e-mail to lissette@thetemple.health or lissetteporras@gmail.com
1601 Town Center Circle Suite A. Weston FL 33326 www.thetemple.healt
Should be Empty:

Weston Med Spa & Cosmetic Surgery

FAMILY HEALTH HISTORY

WOMEN ONLY

MEN ONLY

ANTHROPOMETRIC MEASURES

AUTHORIZATION FOR THE RELEASE OF INFORMATION