General Assessment form (1) "*" indicates required fields Step 1 of 4 25% FacebookThis field is for validation purposes and should be left unchanged.General InformationDate* Name* First Last Age*Date of Birth* Month Day Year Gender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Are you employed?* Yes No OccupationPlease select all that apply:* Work inside the home or telecommuting Work inside the home raising a family (Stay-at-home parent)nd Choice Work outside the home Student How many people live in your home*What are the names and ages of your children? MEDICAL HISTORYHeight*Current Weight*Weight you desire to be:*Do you drink alcohol?* Yes No How many drinks per week?*Do you smoke cigarettes or use any other tobacco products?* Yes No How many packs per day?*Do you or have you ever used drugs?* Yes No Last date of drug use?*List any Medications that you are currently takingMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationMedicationAre you currently taking any food or nutritional/herbal supplements? (This includes Vitamin or mineral supplements)* Yes No Please list*Disease/Condition:Cancer Self Family RelationshipSpecifics (explain, treatments, etc)Cardiovascular Disease Self Family RelationshipSpecifics (explain, treatments, etc)Diabetes Self Family RelationshipSpecifics (explain, treatments, etc)Eating Disorder Self Family RelationshipSpecifics (explain, treatments, etc)Anemia Self Family RelationshipSpecifics (explain, treatments, etc)Autoimmune condition Self Family RelationshipSpecifics (explain, treatments, etc)Depression Self Family RelationshipSpecifics (explain, treatments, etc)Gallbladder disease/gallstones Self Family RelationshipSpecifics (explain, treatments, etc)Heart burn Self Family RelationshipSpecifics (explain, treatments, etc)Hypoglycemia Self Family RelationshipSpecifics (explain, treatments, etc)Hepatitis Self Family RelationshipSpecifics (explain, treatments, etc)Polycystic Ovarian Syndrome Self Family RelationshipSpecifics (explain, treatments, etc)Osteoporosis Self Family RelationshipSpecifics (explain, treatments, etc)Stroke Self Family RelationshipSpecifics (explain, treatments, etc)Heart attack Self Family RelationshipSpecifics (explain, treatments, etc)Anxiety Self Family RelationshipSpecifics (explain, treatments, etc)Food Allergies Self Family RelationshipSpecifics (explain, treatments, etc)Food intolerances Self Family RelationshipSpecifics (explain, treatments, etc)Kidney Disease Self Family RelationshipSpecifics (explain, treatments, etc)High Cholesterol Self Family RelationshipSpecifics (explain, treatments, etc)Thyroid disease (Hypo/hyperthyroidism) Self Family RelationshipSpecifics (explain, treatments, etc)High Blood Pressure Self Family RelationshipSpecifics (explain, treatments, etc)Intestinal Problems Self Family RelationshipSpecifics (explain, treatments, etc)Crohn’s Disease Self Family RelationshipSpecifics (explain, treatments, etc)Menopause Self Family RelationshipSpecifics (explain, treatments, etc)Celiac Disease Self Family RelationshipSpecifics (explain, treatments, etc)OtherAny 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 ExplainDo you have complaints of: (Check all that apply) Poor appetite Bleeding gums Chewing/swallowing Constipation Diarrhea Edema Indigestion Menstrual difficulties Dizziness/lightheadedness Insomnia Acne Dry Skin Bloating Hard stools Gas 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? ExplainAre you a performance or elite athlete?* Yes No Explain the elite training or sport*(type, details/description of your training, Frequency/duration per week, Months/year of participation, Goals/upcoming events)Do you eat or drink any pre-workout, pre-competition, post-workout or post-competition foods, meals, bars, supplements or beverages?*Please list: Have you ever received or currently receives sports nutrition advice* Yes No What and are you still implementing?*What nutrition related questions or concerns do you have regarding your performance training?* Lifestyle/Eating Habits:Where do you eat on a regular basis? (Check all that apply)* Home Desk Room (specify) Work provided eating area Car Restaurants Select AllWhich of these describes your eating style? (Check all that apply)* Fast eater Family members have different food preferences Emotional eater (stressed, board, sad, etc.) Eat too much Eat because I have to Late night snacker Dislike healthy food Travel frequently Do not plan meals Rely on convenience items Love to cook Hate to cook Poor snack choices Negative relationship with food Struggle with eating issues Eat to look good Eat to be healthy Eat for athletic performance Snacker throughout the day Eat healthy but don’t like my body Select AllDo you have the following: (check all that apply)* Refrigerator at home Refrigerator at work Microwave at home Microwave at work Stove Crockpot Blender Grater Select AllDo 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?Please rate your overall stress (0-5)*NO STRESS12345 High stressWhen are you most stressed?*Are you able to do the above de-stressors daily, weekly, or occasionally?*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?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?*Do Biblical or Christian values tend to motivate or encourage you?*Goals/Desired Outcomes:What information or guidance are you hoping to gain from your dietitian?*What information or guidance are you hoping to gain from your dietitian?*Have you made any changes recently to your life that you feel good about?* Yes No What were they?*The nutrition and eating habits that are most challenging for me are:The nutrition and eating habits that are easier for me are:My top 3 priorities that I would like to see change about my health would be:* Please list any additional information you feel may be relevant to understanding your nutritional health* Who could support and encourage you to make the changes we addressed?* When is the best time to contact you?*
