INSURANCE INFORMATION ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
If you want your insurance company to help pay for the session,
 include any information you feel would be necessary to make that happen, 
e.g., name and phone number ofinsurance company, member number, etc. 
You will still need to pay up front, but I will help you get reimbursed in any way that I can.

Why do you want to speak with a Registered Dietitian?

Describe your goals in detail:

What do you feel is missing from your life?

What do you do to relax? How often?

Do you sleep well at night? How many hours do you get? When do you go to sleep? What time do you wake up?

Do you eat certain foods or drink certain beverages when you feel emotionally out of balance,
e.g., anxious, overwhelmed, depressed or whatever feeling you are numbing out?

What is your beverage of choice? What are your favorite foods?

What foods do you "hate"?

Are you struggling with any addictions?

Do you smoke cigarettes? How often? Do you want to stop, eventually?

Do you get sleepy in the afternoon?          ...or do you get tired at another time of day?

On a scale of 1 to 10 (1 = not true, 10 = true):

"I feel connected to my family, my friends and my world."

"I feel peaceful most of the time."

"I am always filled with tension."

"I am a loner."

"I always have people around me. I hate being alone".

"I have low self esteem: I don't like my Self"

"I take time to explore my Self, and cultivate achievable, doable goals."

"I am obsessed with dieting and my body weight."

"I struggle with perfectionism -- I am never happy with my Self."

"I feel loved and cared for. I have a healthy relationship with my Self."

"My body is in good health. I eat nutrient-dense foods most of the time."

"I study nutrition in my spare time"

"I take the time to appreciate my food."

"I eat late at night".

"I wolf down my food."

any medical condition not listed here:

cancer (specify type):

cardiovascular disease 
(heart disease, heart attack, clogged arteries, high LDLs, low HDL's):

depression:

syndrome X (metabolic syndrome)

diabetes / pre-diabetes:

eating disorders:

high blood pressure:

high triglycerides:

immune deficiency 
(a weak immune system):

pain / physical injuries:

Are you on any medications?

Are you taking any supplements?

...any psychological "baggage" you'd like to share, 
that you feel affects your mental-emotional-spiritual health?

Do you consider your Self a chronic dieter? 
Which diets have you embarked upon?

Explain and list any medications you are taking. 

How are they working for you? Do you notice any side effects?

Any vitamins, minerals, herbal remedies, homeopathic remedies, etc. ???

Age:________________________________

Gender:_____________________________

Height (inches):______________________

Weight:______________________________

% + lbs. of Body Fat:___________________

% + lbs. of Lean Mass__________________

Phase Angle (list dates)________________

Body Capacitance(list dates):__________

Intra-Cellular Hydration: ______________

Over All Hydration:___________________

BMR - Basal Metabolic Rate:___________

Activity Level (circle one): light, medium, heavy

What type of work do you do? 
Is it physically demanding or a desk job?

How much sleep do you get each night?

HDL cholesterol:___________________________________________________________________
[HDL = High Density Lipoproteins -- the good stuff]

LDL cholesterol:____________________________________________________________________ 
[LDL = Low Density Lipoproteins -- the bad stuff]

Total cholesterol:____________________________________________________________________

Triglycerides:________________________________________________________________________

Hemoglobin A1C:___________________________________________________________________

Homo-cystiene (An amino acid):__________________________________________________________

Albumin:_____________________________________________________________________________

Glucose:_____________________________________________________________________________

3 Most Recent Blood Pressures:________________________________________________________

_____________________________________________________________________________________

Blood Pressure Response to Exercise:___________________________________________________

_____________________________________________________________________________________

Phase Angle: ______________________________________________________________________

_____________________________________________________________________________________

Have you dieted in the past? 
What type of diet?

Do you still follow strict diets?

Do you prefer structured food plans 
or would you rather wing it from meal to meal.

Do you prefer three larger meals 
or do you prefer to nibble throughout the day

Do you eat in response to stress, boredom, 
anxiety, frustration, anger, etc.

Do you wait until you are hungry to eat?

Do you eat to the point of stuffing yourself 
regularly? sometimes? never?

Do you eat foods you consider to be nutrient-dense 
most of the time?  sometimes?  never? 

Do you drink coffee? Is it organic?
How much do you drink, and when? 

Do you drink tea? What type of teas? 
How often?

Do you use sweeteners? What kind? 
How Often?

Do you drink fruit juice? What kind? 
How Often?

Do you drink diet soda? How much? When?

Do you drink wine, beer, liquor? When and How often?

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Do you practice stretching exercises?

Do you strengthen your muscles with resistance exercises? 
What exercises do you do? How often?

Do you get at least 30 minutes of cardiovascular exercise every day?
What are your top five favorite cardiovascular activities:

• walking,
• running
• dancing
• biking
• hiking
• swimming
• exercise classes
• Tai Chi
• Yoga
• Tennis
• Golf (no carts)
• Other

Do you meditate? How long? How often?

Are you happy?

If not, what do you believe it would take to make you happy?

Do you feel joy on a daily basis...or at least frequently?