Dietitian Patient Questionnaire
Personal Information
Name
*
First Name
Last Name
Age
*
Gender
*
Female
Male
Non- binary
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History and Nutrition Questionnaire
Please indicate whether you have been diagnosed with any of the following diseases or symptoms
Anemia
Anxiety or Panic Attack
Arthritis (osteoarthritis or rheumatoid)
Asthma
Bronchitis
Cancer
Chronic Fatigue Syndrome
Diabetes: Type I
Diabetes: Type II
Prediabetes
Gestational Diabetes
Eczema
Epilepsy
Fibromyalgia
Fungal Infection
Gout
Heart Attack
Heart disease
Hepatitis
High blood fats (cholesterol, triglycerides)
High blood pressure (hypertension)
Hypoglycemia (low blood sugar)
Other
Provide further information if any
How often do you skip meals?
*
Daily
Occasionally (a few times a week)
Rarely (a few times a month)
Never
Do you have any food allergies or intolerances? If yes, list below
Do you take any supplements or vitamins? If yes, list below
Please select the physical activities you are involved often
Stretching/Yoga
Cardio/Aerobics
Streght-training
Sports or Leisure
Other
Expected Budget (3500-5000) or (5000-7000)
*
the above amounts in Jordanian Dinars, included accommodation , meals, activities, consultation and excluded Travel expenses .
Our Terms and Conditions
One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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