assessment form

Nutrition Assessment Intake Questionnaire

Rich Kilchrist RDN LDN Virtual Registered Dietitian Nutritionist (please fill & return prior to appointment)
Name*

First NameLast Name
Have you ever worked with a Registered Dietitian Licensed Nutritionist before?*

YesNoSomeone who was not an RDN
If yes who & what were results
Name & outcomes
Sex (x or y chromosome) We do not entertain the idea of any other.*

MaleFemale
Date of Birth*

MonthDayYear
Date
Phone Number (mobile)*
Email*

Confirmation Emailexample@example.com
Height inches*
Round to nearest inch
Usual Weight in pounds*
Round up to nearest pound
Current Weight*
Round up to nearest pound
Desirable Weight*
Round to nearest pound
Home address*
City*
State*
Zip Code*
Country*
Profession*
Field or industry
Hours per Week Worked*
Number of hours/week
Number of adults in household
16 yrs and older
Number of children in household
15 yrs and younger
What is your main reason(s) for this consultation*
Ultimate goals
Have you attempted weight loss before?*

YesNo
If previous answer was yes check all that apply*

Restrictive Caloric IntakeKetoAtkinsCarbohydrate EliminationLow FatLow SugarIntermittent FastingCarnivorePaleoLiquid onlyVeganSugar BustersMeal replacementBariatric SurgeryMedication AssistedOther
Of those checked please note the length of time on each, the short & longterm outcomes.
Type, Duration, change and final outcome
Reason for discontinuation
Any food allergies or intolerances/dislikes (aversions)*

YesNoOther
If yes please explain
List your favorite foods or type of cuisine.
Spicy, bland, sweet, salty etc..
List all medications & dosages, vitamins, supplements, prescription & OTC, including protein bar/powders, teas & shakes etc*
Name, dose and frequency
List any medical issues past & present. ie high blood pressure, cholesterol, diabetes, hormonal, surgeries, hospitalizations etc.*
Please be as descriptive as possible including dates and/or readings
Please list any psychological issues diagnosis ie depression,anxiety, ADHD or eating disorders*
Previous or currently being treated
Describe any physical limitations or injuries*
Injuries that may limit regular physical activities
Describe your current physical activity routine*
Type, frequency and duration
Is there an activity that you would like to do but think you need to work toward that as a goal?
Marathon, athletic event, competition etc..
How many times a week do you eat out or order takeout*
Including convenience foods
What are some nutrition questions or concerns at this time?*
What do you hope to accomplish by working with a Registered Dietitian and Licensed Nutritionist?*
Should be Empty:

Nutrition Assessment Intake Questionnaire