SDDS Assessment Form Step 1 of 4 25% General InformationDate* Date Format: MM slash DD slash YYYY Name* First Last Age*Date of Birth* MM DD YYYY Gender*MaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email MEDICAL HISTORYHeight*Current Weight*Do you drink alcohol?* Yes No How many drinks per week?*Do you smoke cigarettes?* Yes No How many packs per day?*Do you use drugs?*YesNoExplain*List any Medications that you are currently takingMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationAre you currently taking any food or nutritional/herbal supplements? (This includes Vitamin or mineral supplements)*YesNoPlease list*Disease/Condition:Cancer Self Family RelationshipTreatmentCardiovascular Disease Self Family RelationshipTreatmentDiabetes Self Family RelationshipTreatmentEating Disorder Self Family RelationshipTreatmentFood Allergies Self Family RelationshipTreatmentFood intolerances Self Family RelationshipTreatmentKidney Disease Self Family RelationshipTreatmentHigh Cholesterol Self Family RelationshipTreatmentHigh Blood Pressure Self Family RelationshipTreatmentIntestinal Problems Self Family RelationshipTreatmentCrohn’s Disease Self Family RelationshipTreatmentCeliac Disease Self Family RelationshipTreatmentOtherAny Other Medical Condition (self/Family/Relationship/Treatment) Are you currently being treated for any medical conditions? Yes No ExplainHave you ever been advised by a physician to follow a specific diet? Yes No ExplainAre you currently on that diet? Yes No What changes have you made?Are you currently on any kind of specific diet? Yes No Explain Weight/Diet History:Have you tried to lose weight before? Yes No If yes, what have you done to try and lose weight before (programs, supplements, healthy eating, exercising, etc.)?If you have dieted before, when would be the times that you felt it was difficult or almost impossible to follow the diet (around friends, around immediate family, at events, going out to eat, when you would cook, when another family member would cook, etc.)If you have dieted before, what happened that made you stop?Do you experience periods during which you eat uncontrollably? Yes No When do these periods usually occur and/or when do you tend to eat the most (stressed, depressed, happy, with friends, with family, at job, etc.)?Have you ever been diagnosed with an eating disorder? Yes No Are you currently or have you ever been treated for an eating disorder? Yes No Exercise History:Do you exercise? Yes No how often? Everyday Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month What type of exercise do you participate in? Personal Training Walking Aerobics Dance Running Cycling Team Sports Yoga Weight Lifting Swimming Tennis Racquetball Rowing Hiking Pilate Other Other? Explain Eating Habits:Do you skip meals? Yes No How many times per day do you typically eat?Do you snack? Yes No When do you snack?Do you buy or pack your lunches?Do you eat out? Yes No how many meals per week?What restaurants do you typically choose? 188.8.131.52.184.108.40.206.Who typically prepares the meals at home?How often, per week, is food cooked at home? Everyday Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month Who does the grocery shopping?How many of the following do you drink per day?AlcoholCaffeinated coffeeDecaffeinated coffeeDiet drinks/supplementsDiet soft drinksFruit JuicesGreen TeaRegular TeaRegular Soft DrinksSports DrinksWaterPlease List any drinks that are not on this list that you consume regularly.What foods do you crave?What foods do you avoid?Why do you avoid those foods?Do you have good energy levels? Yes No Can you attribute low energy levels to anything specific (please specify)?Do you consider yourself:* Underweight Normal Weight Overweight What time do you normally go to bed?*Fall to sleep?*Wake up?*How many hours of sleep do you need to feel rested?*How many hours of sleep do you get?*Expectations:Do you want to change your eating habits?* Yes No Are you willing to change your eating habits?* Yes No What do you hope to get out of your meeting with the nutrition coach?*When is the best time to contact you?*EmailThis field is for validation purposes and should be left unchanged.