APC Wellness Nutrition Form
Please fill out this form to the best of your ability, so I can better understand your nutrition needs. All information provided in this form will be strictly confidential.
Date
I am completing this form on behalf of:
Myself
My Child
First Name
Last Name
Email
Phone Number
Sex
Male
Female
Date of Birth
Height
Weight
HEALTH HISTORY
What medical concerns (i.e., pregnancy, prior surgeries), if any, do you have at the present time?
Indicate if you have had blood relatives with any of the following problems: (check all that apply)
Cancer / Diabetes
Heart disease
High cholesterol
High blood pressure
Osteoporosis
Thyroid disorder
I do not have a family history of any of the above conditions.
Do you have complaints about any of the following/ (check all that apply)
Appetite
Constipation
Menstrual difficulties
Bleeding gums
Diarrhea
Seeing in dim light
Bruising
Edema
Sudden weight change
Chewing or swallowing
Indigestion
Stress
None of the above.
Do you use tobacco in any way? If so how much?
Did you recently stop smoking?
Yes
No
Do you enjoy physical activity? Briefly explain...
List any food allergies or intolerances:
MEDICATION HISTORY
List any prescribed or over-the-counter medications, herbal supplements, or vitamin/mineral supplements you take.
DIET HISTORY
Do you follow a special dietary plan, such as low cholesterol, kosher, vegetarian?
Have you ever been recommended a special diet? Briefly explain:
Do you have any problems purchasing foods that you want to buy?
Are there certain foods that you will not eat?
Do you eat at regular times each day?
Yes
No
How many meals per day do you eat, including snacks...
List any foods you particularly like...
How much alcohol do you consume?
None
1-2 per week
3 or more per week
What change(s) would you like to make?
Improve eating habits
Learn to manage my weight
Improve my activity
Improve my cholesterol/triglyceride levels
Other
Please add any additional information you feel may be relevant to understanding your nutritional health...
To tailor your counseling experience to your needs, it would be useful to know your expectations. Please check one of the following to indicate the amount of structure you believe meets your needs:
Tell me exactly what to eat for all my meals and snacks.
I want a detailed food plan.
I want a lot of structure but freedom to select foods.
I want to use the exchange system. (Example: 1 milk, 2 starch, 1 fruit, and 1 fat exchange)
I want some structure and freedom to select foods. I want to use a food group plan.
I don't want a diet.
I want to eat better.
I will just set food goals.
I understand that all information that has been entered on this APC Client Questionnaire is confidential. I agree to be contacted by APC Wellness for the purposes of nutrition and wellness assistance by phone, email, or mail.
I want to subscribe to the mailing list.
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