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Client ID: PERSONAL INFORMATION Date: .

Name: _________________________________________

Address: _______________________________________

________________________________________________

Cell Phone: ___________________________________

Home Phone: _________________________________

Email: __________________________________________

Date of Birth (DD/MM/YYYY): ________ /____ /_______

Height: ___________ Weight: ___________

Age: ______________ Gender: Male Female

Date of Last physical: ____________________________

Physician Name: ________________________________

Dr. Address: ____________________________________

________________________________________________

Dr. Phone: ______________________________________

Permission to contact Dr? Yes No

WC: ______ IBW:_______ BMI:_____, ______________

REASON FOR VISIT

Reason for visit: __________________________________________________________________________________

_________________________________________________________________________________________________

Health Goals and Priorities:_________________________________________________________________________

_________________________________________________________________________________________________

Preferred clinical outcomes: Improvements in Blood Sugar A1C Total Cholesterol LDL HDL

Waist Circumference Blood Pressure Triglycerides Menstruation

Weight. Goal weight? _______, time frame: ________. Why? _______________________________________

Other Symptoms: _____________________________________________________________________________

How did you hear about this service? Google Dietitians of Canada Dr. Referral Local/Street

Facebook Instagram Friend / Family. Who may we thank for this referral:

YOUR FAMILY’S MEDICAL HISTORY

Diabetes, Who? ______________________ Controlled by Diet________, Pills_______, Insulin__________________

Heart Attack / stroke, Who? _____________________________________ Age(s): ____________________________

High Cholesterol, Who? _______________________ High blood pressure, Who? __________________________

Osteoporosis, Who? ________________ Cancer, type _______________, Who? ___________________________

Other condition(s): _________________________________________________________________________________

___________________________ Who? ______________ /__________________________ Who?_______________

PERSONAL MEDICAL HISTORY

Past Hospitalizations:

Or Surgery:

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Please indicate all past and present medical conditions

Heart Attack / Stroke; date:

Diabetes, type: ____________(also incl. pre or gestational)

Metabolic Syndrome

Hypertension / high blood pressure

Polycystic Ovary Syndrome or Prostate Conditions

Menopause; complaints __________________________

Digestive problems: ____________________________

High blood glucose, A1C or insulin resistance

Overweight / Obesity / Waist Circumference

All other Diagnosis:

Underweight

Eating disorder (bulimia, anorexia, binge)

High cholesterol or blood lipids or triglycerides

Non-alcoholic fatty liver disease

Kidney / Gallbladder / Urinary track problems

Osteoporosis / Osteoarthritis

Thyroid: ___________________________________

Cancer, type: ______________________________

Anxiety / Depression, _______________________

Sleep Apnea

Medications: (include all, if space needed please use margin or back pages)

Prescription or Other Amount / Dose Times Taken Reason for Taking Changes (Staff only)

Vitamin/Herbs/ Supplement Amount / Dose Times Taken Reason for Taking Changes (Staff only)

Lab Values: Please obtain recent lab results from your Dr. if you don’t have number, indicate H:high, L:low, N:normal

______ Blood Pressure ______ Fasting Glucose ______ A1C ______ Total Cholesterol ______ LDL-C

______ HDL-C _____ Triglycerides Other: ________________________________________________________

Menstrual History Not Applicable

First Menstruation Age: ______ Last Menstruation date: ___________ Menstruation history: Normal

Irregular: ____________________________________________________________________________________

Other symptoms: Absent periods Excess hair growth (facial, chest, etc) Hair loss/thinning hair

Acanthosis nigricans/dark skin patches Infertility/difficulty getting pregnant Acne

Pregnancy History Not Applicable

Age of First Pregnancy: ______ # Previous Pregnancies: _____ # Previous Births: _______ (twin, triplet etc)

Miscarriage? Yes, Reason: Abortion? Yes, Reason:

Type of birth for each pregnancy: ____ Term ____ Premature Natural/Vaginal: ____ Caesarean: _____

Other complications: ____________________________________________________________________________

Previous birth weight of baby(s): Low birth weight (<2.5kg): ____ Large of Gestational Age (>4kg): ____

Last Pregnancy date:___________ Pre-Pregnancy Weight: _________ Post-Preg Weight: _________

Where you diagnosed with gestational diabetes: No Yes_____________________________________

Currently pregnant: Not Applicable Pre-preg Weight: _________ Expected delivery ______________

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WEIGHT HISTORY

Other areas you tend to gain fat/weight at; Location: _________________ Measurement: ________________

Weight History: 1 year ago: ________ 5 years ago: ________ 10 years ago: _________

Previous diets (list all):_____________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Were they successful (give reasons): _______________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Lifestyle Events and Body Weight Graph: Please plot your weight history (at least since high school) with

corresponding life events (marital status, occupation, illness, medication, pregnancy, menopause, stressful life events)

SOCIAL & LIFESTYLE INFORMATION

Ethnicity: White/Caucasian Middle Eastern Aboriginal South Asian Other: ___________________

Marital Status: Single Married Engaged Separated Divorced

Children: None Yes, 0-18 year olds Yes, 18+ year olds Are your kids picky eaters? Yes No

Highest Level of Education: Grade School High School College/University Degree Masters/PhD

Work Status: Employed Not employed Retired Disabled Student

Occupation: ________________ Hours at work: _______ Business travel? _____________ How often? _________

Transportation: Car Bus Taxi Train Need ride from others Other: _____________________

Do you see specialists (or health care providers) other than your primary physician? No Yes,

Reason?

Contact detail of specialists: Permission to contact? Yes No

Wei

ght

Age/Years

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Medical Condition(s) have caused a problem in these areas of my life: family life social activities travel

work/school sexual relations finances sports/exercise peace/contentment everyday activities

Main support people: Spouse Parent(s) Child Brother Sister Friend Doctor Other:

Best way you learn: Discussion Videos/Graphics Listening Reading Doing/Touching In Groups

Challenges and Competitions.

Learning barriers: Worry/fear Attention deficit Language Memory Lack of confidence Can’t sit

long enough (too fidgety) Other

Stress level: (lowest) 1 2 3 4 5 (highest)

Major stressors (job, family, commute, finance, boss, health etc):

How do you deal with stress:

Sleep patterns: How many hours do you sleep daily: ____________hours per day / night

Do you experience difficulty falling asleep: No Yes ________________________________________________

Do you experience difficulty staying asleep: No Yes _______________________________________________

Describe your sleeping pattern (time to bed, disturbances, sleeping aids/pills, etc): __________________________________

__________________________________________________________________________________________________

Physically activity: Dr. ok’d exercise? No Yes

Are you physically active? No Yes , Type:

How often (days per week or month): ____________________________ How long (minutes): _______________________

Do you track you physical activity or steps? No Yes, How:

List your barriers to exercise (eg. time, injury/pain, etc):

Are you prepared to include exercise to your weekly schedule? (not ready) 1 2 3 4 5 (ready)

Strength: # of second you can hold a plank: _________________ Date: ___________________

Smoking: Never I quit Yes, How many: ________ Packs Cigarettes Cigars a day

Have you tried to quit? ______________________ Plans to quit? ________________________________

FOOD & EATING PATTERN

Food Allergies, intolerances or restrictions (religious or other):

No. of people in your household: ___________ Are you responsible to feed everyone:

Who cooks: ______________ How often: __________________ Who plans meals/menu items:_______________

Who gets groceries: ______________ How often: ____ per week or ____ per month. Where? _________________

How would you describe your eating pattern: Poor Fair Good Excellent

# meals per day: ______ # of snacks per day: ______ When is your heaviest meal?

Do you crave food: No Yes (circle): Sweets Fatty/fried food Salty food Example? _______ When: _____

How many homemade meals do you eat: ___________ per week

How many meals per week do you eat out for: Breakfast ____ Lunch ____ Dinner ___ Fast foods __________

Common restaurants/fast food places: What are your regular meals/beverages orders:

Do you track your eating? No Yes, How:

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Typical intake: Please write the number of each food you eat per day, week, month, if not - write “X” in never below:

Food Day Week Month Never

Beef/lamb/pork

Poultry

Eggs

Fish

Sausage/bacon/Hot dog

Fried food/chips

Legume/lentil

Milk Whole 2% 1% skim

soy almond other

Yogurt

Cheese; ___%Milk Fat

Butter/Margarine

Food Day Week Month Never

Water (in cups or ml)

Juice/Soda

Pasta/Rice

Bread/Pita/Bagel

Whole Grains

Potatoes/peas

Other Vegetables

Fruits

Soy products

Nuts/Seeds

Dessert/Sugary food

Alcohol

Tea/Coffee

Your Food Diary: This is the time to take notice of your own eating behaviours & patterns. What you eat, how much and

why are some of the important things to look at - which we usually don’t concentrate on until you are told to keep a diary.

Remember to include every single food item you ate, common things we tend to forget are: gums, nuts, seeds, coffee/teas &

specialty beverages and sodas, doughnuts, cookies, chips, cake, etc. Make sure you include every foods item and activity

WEEK DAY 1 Day of the Week: Date:

Time Amount Foods & Beverages Activities include work, travel

Why you chose those foods?

Who was with you What were you doing?

Time you woke up:

First Meal / Food / Bev.

Dinner

Evening snacks / Foods

Bedtime

Midnight Snack/activities

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WEEK DAY 2 Day of the Week: Date:

Time Amount Foods & Beverages Activities include work, travel

Why you chose those foods?

Who was with you What were you doing?

Time you woke up:

First Meal / Food / Bev.

Dinner

Evening snacks / Foods

Bedtime

Midnight Snack/activities

WEEKEND Day of the Week: Date:

Time Amount Foods & Beverages Activities include work, travel

Why you chose those foods?

Who was with you What were you doing?

Time you woke up:

First Meal / Food / Bev.

Dinner

Evening snacks / Foods

Bedtime

Midnight Snack/activities

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Waiver & Consent Form:

This is a required step for booking your Nutrition Appointment with Modest Nutrition. In order to ensure

the safety or your medical/health information and your nutrition-medical care, we require that you read

and agree to the following conditions:

I hereby grant permission to my Registered Dietitian (at Modest Nutrition), to contact my

physician(s) and health care providers, when needed, to obtain information relevant

to my nutrition treatment and counseling. This may be accomplished by letter, phone, fax, or

email; as per the Personal Information Protection and Electronics Documents Act (PIPEDA).

I agree to have my Registered Dietitian keep records of our visits and to file these in a secure

and appropriate place, which will be held in strict confidence.

I consent to exchange of information of my dietetic treatment to be send electronically (if

needed) to the email that I provided above, which is a secure and safe address that only I have

access to. I acknowledge that privacy cannot be guaranteed in electronic communication and

it is both mine and my dietitian’s responsibility to maintain confidentiality.

I acknowledge the information provided to me by my Registered Dietitian is designed to meet

my personal dietary needs. It is NOT suitable for any other individuals and will not be transferred,

copied or sold to another person.

In order to benefit from the treatment prescribed, I will inform either my physician or dietitian of

any changes I make to my diet. It is my responsibility to report any side effects or problems

immediately and to make the necessary adjustments to my treatment plan with my physician

and/or registered dietitian. I will not hold my physician or dietitian responsible for any

complications that result from my failure to comply with either of the above.

Cancellation & Refund Policy We do NOT issue a refund under these conditions:

After you have completed your appointment and the services are rendered

If you cancel or reschedule within 24-hours of your scheduled appointment

If you fail to book or reschedule an appointment within 30 days of payment

One year after you buy. All packages expire one year after date of purchase

It is your responsibility to book and keep your appointments.

All no shows will be regarded as a completed visit!

I declare that the information provided is true and accurate at the time of signing, and that

I have understood and agreed to the above.

Signature: ______________________ Date: ________________

PRINT NAME: ___________________________