New Client Form Step 1 of 9 11% Date* MM slash DD slash YYYY Name* First Middle Last Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Martial StatusSelectSingleMarriedDivorcedLegally SeparatedWidowedSex Male Female Other Email* Cell Number*Home Number if applicableHIPPA Authorization-In order to be HIPPA compliant, please indicate your approval of being contacted either by phone or email to discuss your related counseling issues. Yes No Referring physician, if applicable Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please list current medical diagnoses or concerns.Height (inches) Weight (pounds) Please note any surgeries or hospitalizations.Are you taking any prescriptions or over the counter medications? Yes No If yes, please list medications here along with dosages.Are you taking any nutritional supplements? Yes No If yes, please list here along with dosages. Do your immediate relatives have a history of: Cancer Heart Disease High Blood Pressure Diabetes Osteoporosis Gastrointestinal Problems Obesity Please provide additional information if you checked above.Which of these diets have you tried? Jenny Craig Weight Watchers Seattle Sutton Low Carbohydrate/Sugar Low Fat High Fiber Low Calorie Fasting Keto Other Please note which plans seemed helpful. If "other" is marked, please describe.How often do you eat restaurant or carry out food on a weekly basis? Never 1-2x 3-5x Daily How often do you grocery shop on a weekly basis? Never 1-2x 3-5x Daily How often do you cook on a weekly basis? Daily 1-2x 3-5x Never Do you eat in response to any particular emotion or stress? If so, please describe.Please describe leisure time activities you enjoy.Do you have any food allergies or foods you cannot tolerate? Please describe. Do you do any structured exercise? If so, please describe (treadmill, video, walking outside, biking). Please indicate how frequently you do these activities.Please note if you have any of the following available at home or a fitness facility. Treadmill Elliptical Stationary Bike Rower Free Weights/Resistance Machines Videos Other Please describe your goals for nutritional counseling.PhoneThis field is for validation purposes and should be left unchanged. Δ
