Scheduling Email Online Coaching with GIBNC

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Are you an existing* patient of The GI and Bariatric Nutrition Center* This field is required."Existing" means that you have seen a dietitian in this practice in the past 18 months. If it has been more than 18 months please email us on https://nutrition5.com/contact-us/
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You have indicated that you have not seen one of our dietitians in the past 18-months or are seeking other services than a 30-minute follow-up. This requires special scheduling, please contact our office regarding scheduling 443-490-1240 or email us www.nutrition5.com/contact-us

If this is a mistake click on the "previous" button below.
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Email Coaching Terms and Limitations:

Coaching services are for existing* patients of The GI and Bariatric Nutrition Center. *If you have not seen a dietitian with our office in more than 18-months, you are considered a new patient.

LABWORK Coaching is meant to address non-complex and non-layered issues. They are intended to be utilized for labwork reviews to address any concerns such as deficiencies.

FOOD/ EXERCISE LOG Coaching is designed for our dietitian to review your food decisions and eating patterns. This can help you stay on track with your weight-loss goals and not hit plateaus or regain weight after your procedure.

We are limited to addressing 1 topic during a single coaching request. If you want both labwork and food/exercise logs reviewed this will be two separate requests.

This form is for email coaching only, if you feel you need to address more than your labwork or food/exercise log please contact our office to schedule a follow-up telehealth appointment. Existing patients* may schedule a 30 to 60 minute follow-up with the dietitian online at https://form.jotform.com/GIBNC/Bariatric-Follow-Up (Examples: if you want to address concerns outside of labwork or food/exercise logs like a recent weigth gain/plateau, carb counting for diabetes, pregnancy, thyroid, etc. this will require a follow-up outside of this online coaching.)

This will be an email response service only. It is YOUR responsibility to make sure our office.communication@gibnc.net email address is in your safe senders and that the email address you provided is a working email that you check regularly. We will not call you for email coaching services.

There is an out-of-pocket expense for this service. We will collect the payment for this service today, at the time of scheduling. We accept all major credit cards.
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By agreeing below you agree to the terms of our Email Coaching* This field is required.
AGREEDISAGREE
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You have indicated that you disagree with the terms and limitations. Please contact our office www.nutrition5.com/contact-us

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Patient Name* This field is required.
First Name
Last Name
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Email Address for Dietitian to correspond with you* This field is required.This will be the email address we correspond with you regarding appointments, classes, and digital education materials.
example@example.com
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Cell Phone Number* This field is required.Our office returns calls from 240-452-0423 and 240-347-1011, SMS messages are sent from 240-452-0422.
Please enter a valid phone number.
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Height* This field is required.
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Current Weight* This field is required.Weight in POUNDS
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What Bariatric Vitamins are you taking DAILY?* This field is required.If none, check None
nutraMetrix
Bariatric Advantage
Celebrate
Other
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Multi-Vitamin
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Calcium
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B-12
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Iron
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Multi-Vitamin
Calcium
B-12
Iron
nutraMetrix
Row 0, Column 0
Bariatric Advantage
Row 0, Column 1
Celebrate
Row 0, Column 2
Other
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NONE
Row 0, Column 4
nutraMetrix
Row 1, Column 0
Bariatric Advantage
Row 1, Column 1
Celebrate
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Other
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NONE
Row 1, Column 4
nutraMetrix
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Bariatric Advantage
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Celebrate
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NONE
Row 2, Column 4
nutraMetrix
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Bariatric Advantage
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Celebrate
Row 3, Column 2
Other
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NONE
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If "Other" vitamins/ brand please describe below.* This field is required.
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Please select ONE* This field is required.You must attach your labs or food/exercise log to this request to proceed.
Lab Work Review ($45)
Food/Exercise Log Review ($45)
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Are you experiencing any of the following? (Check ALL that apply or NONE)* This field is required.
Dark-colored urine
Nausea
Vomiting
Sensitivity to the smell of foods
Constipation
Diarrhea
Hair Loss
Muscle Cramps/ Spasms
Muscle Weakness
Fatigue
Abnormal Heart Rhythm (not previously diagnosed)
Chewing a lot of ice or craving non-nutrient items (like chalk or clay)
Numbness in legs, hands or feet
Problems with Balance
Memory Loss/ Dementia
Changes in vision
NONE
Other
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Please list any other symptoms or specific concerns regarding your lab work. (If none, type NONE”)* This field is required.
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Please attach the lab work you wish for us to review. Lab work should be no more than 6 months old.* This field is required.We do not accept image files. Please upload a single PDF or Word Doc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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What time was meal ONE consumed?* This field is required.
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Description of what was eaten. INCLUDE AMOUNT. * This field is required.Example: 1 cup Chobanni Plain Greek Yogurt, 8 oz of black coffee, 2 turkey sausage links, 1 hard boiled egg.
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Is this a typical day?* This field is required.
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If "no", please describe your typical eating pattern and what made this meal unusual. * This field is required.
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What time was meal TWO consumed?* This field is required.
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Description of what was eaten. INCLUDE AMOUNT. * This field is required.Example: 1 cup Chobanni Plain Greek Yogurt, 8 oz of black coffee, 2 turkey sausage links, 1 hard boiled egg.
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Is this a typical day?* This field is required.
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If "no", please describe your typical eating pattern and what made this meal unusual. * This field is required.
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Did you consume a third meal today?* This field is required.
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What time was meal THREE consumed?* This field is required.
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Description of what was eaten. INCLUDE AMOUNT. * This field is required.Example: 1 cup Chobanni Plain Greek Yogurt, 8 oz of black coffee, 2 turkey sausage links, 1 hard boiled egg.
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Is this a typical day?* This field is required.
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If "no", please describe your typical eating pattern and what made this meal unusual. * This field is required.
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Did you consume a fourth meal today?* This field is required.
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What time was meal FOUR consumed?* This field is required.
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Description of what was eaten. INCLUDE AMOUNT. * This field is required.Example: 1 cup Chobanni Plain Greek Yogurt, 8 oz of black coffee, 2 turkey sausage links, 1 hard boiled egg.
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Is this a typical day?* This field is required.
Yes
No
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If "no", please describe your typical eating pattern and what made this meal unusual.* This field is required.
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What type of fluids did you consume yesterday? * This field is required.List the approximate number of ounces. (Ex. 48oz water, 12oz seltzer, etc.)
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How many times did you eat out last week?* This field is required.
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Is this a typical week?* This field is required.
Yes
No
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If "no", how many times is typical?* This field is required.
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What kind of exercise are you doing now?* This field is required.If none, state "none"
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How many times a week are you exercising?* This field is required.
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What is the duration of time spent exercising each day?* This field is required.
15-30 minutes
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over 60 minutes
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If you're not exercising is there a physical reason as to why you are not able to at this time? * This field is required.Example: knee pain, back pain, no time, no equipment, no motivation
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Eating Habits * This field is required.
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1. Include protein every time you eat.
2. Avoid skipping meals and eat every 3-4 hours.
3. Drink 48-64 ounces daily of water or 0-15 calorie beverages.
4. Avoid Caffeine
5. Avoiding carbonated drinks
6. Use healthy cooking methods: baking, steaming, broiling, grilling, avoiding deep fat fried foods, etc.
7. Eat a combined 5 servings of fruits and non-starchy vegetables per day.
8. Limit dining out and carry into less than 1-2 times a week and select healthier options when away from home.
9. Eat every 3-4 hours with no snacking in-between meal times.
10. Avoid emotional or mindless eating.
11. Slow down with eating; take 20-30 minutes to eat. Take small bites and put utensils down in-between bites to focus on chewing,
12. Avoid large portions or eating to the point of discomfort.
13. Monitor what you eat by reading food labels as taught in class, keeping mindful food logs from initial appointment, using health and or fitness apps or websites.
14. Decrease alcohol to one drink 1-2 times per month or less.
1. Include protein every time you eat.
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List new lifestyle changes you have made since your surgery:* This field is required.Examples: Meeting protein goals, exercising, socializing, dating, reading food labels, practicing better habits, better hygiene, returned to work
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Select the date you wish to receive a response by* This field is required.Please put this on your calendar. The dietitian will EMAIL you with the details of your lab or food/exercise review from the following email address: OFFICE.COMMUNICATION@GIBNC.NET. This coaching service is an EMAIL ONLY service. You will not be called by our office.
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I understand that I will receive a an email with my review from OFFICE.COMMUNICATION@GIBNC.NET on the date I have scheduled my review.* This field is required.
YESNO
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By selecting the "I Accept", you are consenting to the electronic delivery of your paperwork. You also agree that the email address you provided at the beginning of this form is monitored for communications. All emails from our office will come from OFFICE.COMMUNICATION@GIBNC.NET* This field is required.
Agree
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ORDER SUMMARY
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Lab Work ReviewOnce your review is complete the dietitian will email you her recommendations within 7 business days of receipt. Please check your email for an email from OFFICE.COMMUNICATION@GIBNC.NET. YOU WILL NOT RECEIVE A PHONE CALL.
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Food & Exercise Log Review. Once your review is complete the dietitian will email you her recommendations within 7 business days of receipt. Please check your email for an email from OFFICE.COMMUNICATION@GIBNC.NET. YOU WILL NOT RECEIVE A PHONE CALL.
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Signature: are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.* This field is required.
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