| Date: | |
| Client Full Name: | |
| Email: | |
| Phone: | |
| Precounseling Food Log Submitted | |
| Reason(s) for Contacting us: |
|
| Goals: |
|
Current Eating Pattern (typical foods eaten,
CHO, protein, fat, fruit/vegetables, restaurant
food) |
|
| Allergies and Food Sensitivities: |
|
Dietary Limitations (dislikes,
cultural/religious/ethnic preferences): |
|
| Time/Prep Issues: |
|
| Sleep Patterns: |
|
| Stress/Environmental Issues: |
|
| Weight History: |
|
| Family Support: |
|
Exercise Patterns if any (time, day, duration,
type): |
|
| Gender: | |
| Age: | |
| Height: | |
| Current Weight: | |
| Peri/Post Menopause: | |
| Med Hx: |
|
| Family Hx: |
|
| Medications, Supplements, OTC: |
|
Labs (Glucose,Albumin,BUN,
Creatinine,Sodium,Potassium,
Cholesterol,HDL/LDL,Triglycerides,Hemoglobin,Hematocrit,Other) |
|
| BMI: | |
| Target/Goal Weight: | |
| Primary Dietary Issues: |
|
Understanding, Motivation, Ability to Follow
Recommendations: |
|
| Services interested in: |
|
| How did you here about us? | |
|
|
| | |
|
