Kathy Levine MS, RD, CDN
Home
About
Contact
Resources
Testimonials
For New Clients
Registration and Nutrition Assessment Form
Either
download
and print registration/nutrition assessment form and bring to initial visit
OR
fill out digital form below.
Patient Information
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Main Phone Number
*
Cell Phone Number
*
Work Phone Number
*
Email
*
Marital Status
*
Single
Married
Divorced
Date of Birth
*
Physician
*
Address of M.D.
*
Line 1
Line 2
City
State
Zip Code
Country
MD Phone Number
*
MD Fax Number
*
Nutrition Assessment
Reason for nutrition consultation
*
Age
*
Sex
*
Male
Female
Blood Pressure (if known)
*
Have you ever smoked?
*
List children, ages
*
Describe your medical history
*
Describe your family health history: At what age did they develop disease? Were they obese? Did they smoke?
*
Medications
*
Herbs/Vitamins/Supplements
*
Do you suffer from:
*
constipation
diarrhea
Do you participate in regular physical activity? What type? How often? Do you enjoy it?
*
When do you go to bed?
*
How is your energy level?
*
When do you wake?
*
How is your stress level?
*
How do you deal with stress?
*
What is the most you've weighed as an adult, and at what age?
*
What is the least you've weighed as an adult, and at what age?
*
Describe weight history, diets tried, weight lost, how long weight loss remained
*
Have you used laxatives, vomiting or excessive exercise for weight loss?
*
Fasting
*
Are your menstrual periods regular?
*
Food allergies
*
Food intolerances
*
Ethnic culture
*
Do you have any religious/ethical/cultural food restrictions?
*
How much of the following do you consume daily?
Milk
*
Yogurt
*
Hard cheese
*
Juice
*
Water/Seltzer
*
Soda
*
Coffee/Tea
*
Alcohol
*
What are your five favorite foods?
*
Foods you particularly dislike
*
Do you eat when you are:
*
Tired
Depressed
Bored
Stressed
Happy
Frustrated
Do you eat when hungry and stop when satisfied? If not, please describe factors that influence when you begin to eat, and at what point you stop
*
Do you feel you eat fast?
*
How many days per week do you eat:
Breakfast?
*
Lunch?
*
Dinner?
*
How many times a day do you snack?
*
When do you usually snack?
*
How often do you eat out or order in? Which meals, what types of restaurants?
*
Who shops for food?
*
Who prepares the food?
*
Do you have a stove, refrigerator, microwave? Is there anything that would prevent you from cooking?
*
Do you read food labels? What do you look for?
*
Occupation
*
Travel time to work
*
Do you travel for work?
*
Work hours
*
Do you like your job?
*
Would you like to change your eating habits?
*
Yes
No
Why?
*
Please read the following information carefully. Clicking the "I agree" checkbox indicates your responsibility for this account and your guarantee of payment of all charges as they accrue. It is your responsibility to verify that your insurance plan covers your diagnosis for nutritional counseling.
I agree to reimburse you for office visits if insurance company doesn't pay.
I will pay for missed appointments unless I give 24 hours notice or it is a true emergency. Please note: insurance does not cover missed appointments. You will be responsible for paying my usual fee.
I authorize Kathy Levine to exchange records and information with my physician.
Click check box to agree to terms
*
I agree
For office use only:
Height
*
Weight
*
BMI
*
IBW
*
ABW
*
BMR
*
Meal Plan
*
TC
*
LDL
*
HDL
*
CHOL/HDL
*
BG
*
HbA1C
*
TG
*
Thyroid
*
TC
*
TC
*
LDL
*
LDL
*
HDL
*
HDL
*
CHOL/HDL
*
CHOL/HDL
*
BG
*
BG
*
HbA1C
*
HbA1C
*
TG
*
TG
*
Untitled
*
Thyroid
*
TC
*
LDL
*
HDL
*
CHOL/HDL
*
BG
*
HbA1C
*
TG
*
Thyroid
*
TC
*
LDL
*
HDL
*
CHOL/HDL
*
BG
*
HbA1C
*
TG
*
Thyroid
*
Submit