SDDS Assessment Form Step 1 of 4 25% General InformationDate* MM slash DD slash YYYY Name* First Last Age* Date of Birth* Month Day Year Gender* Male Female Address* 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?* Yes No Explain* List any Medications that you are currently takingMedication Medication Medication Medication Medication Medication Medication Medication Medication Medication Medication Medication Are you currently taking any food or nutritional/herbal supplements? (This includes Vitamin or mineral supplements)* Yes No Please list*Disease/Condition:Cancer Self Family Relationship Treatment Cardiovascular Disease Self Family Relationship Treatment Diabetes Self Family Relationship Treatment Eating Disorder Self Family Relationship Treatment Food Allergies Self Family Relationship Treatment Food intolerances Self Family Relationship Treatment Kidney Disease Self Family Relationship Treatment High Cholesterol Self Family Relationship Treatment High Blood Pressure Self Family Relationship Treatment Intestinal Problems Self Family Relationship Treatment Crohn’s Disease Self Family Relationship Treatment Celiac Disease Self Family Relationship Treatment Other Any Other Medical Condition (self/Family/Relationship/Treatment) Are you currently being treated for any medical conditions? Yes No Explain Have you ever been advised by a physician to follow a specific diet? Yes No Explain Are 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? 1. 2. 3. 4. 5. 6. 7. 8. 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?Alcohol Caffeinated coffee Decaffeinated coffee Diet drinks/supplements Diet soft drinks Fruit Juices Green Tea Regular Tea Regular Soft Drinks Sports Drinks Water Please 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?* CommentsThis field is for validation purposes and should be left unchanged.