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?
If yes who & what were results
Name & outcomes
Sex (x or y chromosome) We do not entertain the idea of any other.
Date of Birth

MonthDayYear
Date
Phone Number (mobile)
Format: (000) 000-0000.
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?
If previous answer was yes check all that apply

Other
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)

Other
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?
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Nutrition Assessment Intake Questionnaire