Nutrition & Dietitian Consultation Form
General information Sheet
Name
Age
Date
Country
Select Country
City
Select City
Phone
Sex:
M
F
Height
Weight
Occupation
How were you referred?
What are your main health concerns or conditions?
Please list any medication or food supplements you are currently taking:
Please list any medical test results you have, such as blood test:
Please list illnesses in your family such as heart disease, cancer, TB:
DIET: What are example of typical breakfast for you?
/
Beverages
Mid-Morning snacks?
/
Beverages
What are typical lunches for you?
/
Beverages
Mid-afternoon snacks?
/
Beverages
What are typical dinners foe you?
/
Beverages
Evening snacks?
/
Beverages
How often and what kind of exercise do you do?
About How many hours of sleep do you get per night?
Symptoms Sheet
Checked ✅
any conditions or symptoms that presently describe you.
Joint Pain
Joint Stiffness
Arthritis, Osteo
Arthritis, Rheumatoid
Muscle Pain
Muscle Weakness
Muscle Cramps
Bursitis
Fractures
Osteoporosis
Gout
Sweet Cravings
Sugar Reactions
Irritable Before Meals
Hypoglycemia
Crave Starches
Fat Cravings
Other Food Cravings
Food Allergies
Excessive Hunger
No Hunger
Diabetes
Rapid Heart Rate
Skipped Heart Beats
Heart Palpitations
Heart Attack
Congestive Heart Failure
Low or High Blood Pressure
Arteriosclerosis
High Cholesterol
High Triglycerides
Cough
Bronchitis
Asthma
Post-nasal Drip
Sinus Congestion
Allergies
Emphysema
Fatigue
Hypothyroidism
Low Body Temperature
Cold in Winter/Dry Skin
Tend to Gain Weight
Hyperthyroidism
Acne
Eczema
Fungal Infections/Candida
Psoriasis
Hives
Hair Loss
Slow Wound Healing
Cataracts
Glaucoma
Meniere’s Disease
Tooth Decay
Excessive Plaque on Teeth
Gum Disease
Infections/Viruses
Tumors/Cancer
Multiple Sclerosis
Parkinson’s Disease
Scleroderma
Anger
Anxiety
Bipolar Disorder
Brain Fog
Confusion
Depression
Irritability
Mind Races
Mood Swings
Obsessive/Compulsive
Panic Attacks
Poor Memory
Schizophrenia
Trouble Sleeping
Autism
Attention Deficit
Hyperkinesis
Dyslexia
Seizures
Learning Disability
Mental Retardation
Delayed Development
Bladder Infections
Kidney Infections
Trouble Urinating
Frequent Urination
Painful Urination
Kidney Stones
Water Retention
Constipation
Diarrhea
Intestinal Gas
Bloating
Heartburn
Ulcer
Stomach Pain
Colitis
Gall Stones
Fissures
Hemorrhoids
Cirrhosis
Diverticulitis
Tend to Gain Weight
Tend to Lose Weight
Anemia
Easy Bruising
Drug Addiction
Alcoholism
Smoking
Women
Premenstrual Syndrome
Water Retention
Cramps
No Menstruation
Heavy Periods
Light/Irregular Periods
Ovarian Cysts
Fibroid Tumors
Abnormal Pap Smear
Menopause
Fibrocystic Breasts
Breast Tumors
Yeast Infections
Hot Flashes
Men
Prostate Problems
Impotence
Infertility
Other Symptoms or Comments: