First Appointment Questionnaire for Zoe Connor Dietitian

First Appointment questionnaire – for Zoe Connor Dietitian

Date:

CONTACT DETAILS:

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for main contact

Name:
Address:
Phone number:
Email address:
Consent to email: / As we may be exchanging sensitive information about health, please confirm that you consent to us corresponding by email: Yes / No
If appointment is for you: next of kin and phone number:
If appointment is for someone else - name of patient:
Relationship to patient:
DOB of patient:
GP name and address:
GP phone number:
Consent to correspond with GP: / As standard professional practice I will correspond with your GP to let them know I am advising you, and to ask them to share any relevant information from your history. By having a consultation with me you are consenting to this – please discuss with me if you don’t want this to happen.
Other professional contacts: / Please list names, addresses and phone numbers of other relevant professionals involved who I will copy into contact with your GP: e.g. consultants, health visitors, practice nurses, dietitians, nutritionists:
How did you hear about my services?:
Can I use anonymous examples from your treatment and assessment in training others? / Part of my work involves educating dietitians and other health professions and raising awareness of dietary issues in general. I do this via education sessions, writing chapters for books, and writing on my website. Would you give your permission for me to use information from your assessment and treatment like this in a completely anonymous way?
Yes/No

Current issue

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What are your reasons for contacting me – what are your current diet-related issues or worries?
In an ideal world, what would you like to come out of appointments with me?

Medical history:

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How would you score your current state of health on a scale of 1-10 with 10 being great, and 1 being poor:
Current diagnoses and/or medical problems and rough date they started:
Past medical problems that are now resolved, and rough dates of when they started and resolved:
Current medications and how often you take them:
Are you awaiting any medical tests or results or operations? Give details:
Any bowel problems not stated above – such as constipation, wind, diarrhoea, etc:

Medical nutrition history:

Known food allergies/ intolerances, and for each, what was the worst reaction to this food, and roughly when:
Results of any allergy tests:
Have you ever been tested for Coeliac disease? Please give rough date and results:
Do you or have you ever had an eating disorder – please give details:
Do you have or have you ever had nasogastric (NG), gastrostomy or other tube feeds? If yes – please give details.
Do you have, or have you ever had any nutritional deficiencies e.g. iron-deficiency? Please give details.
Are you taking any prescribed nutritional supplements e.g. iron, calcium; or medical nutrition products e.g. Ensure, Fortisip, Scandishake, Calogen, Paediasure, etc – please give details:
Have you ever been told your weight or growth is of concern – please give details:
Recent weight and height if relevant:

Social and psychological issues:

Who do you live with?
Profession/job/studies and rough hours:
Do you /did you receive any special education support?
Are there any social or psychological issues I should know about, e.g. recent traumas or upheavals?

Current Diet

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What dietary problems do you have and when did they start?
What do you think the reasons for the dietary problems are?
Have you seen a dietitian or nutritionist before? If so, when, and what was the advice given? What advice was helpful?
Do any other members of your family have any dietary issues? Give details:
What are your preferred foods and drinks?
What foods and drinks won’t you or don’t you eat/drink
What do you think of your current diet? Do you think you eat healthily? What do you think you could improve?
What is your usual diet – list what and when you normally eat and drink from waking to bedtime (and night time if appropriate) :
Finally is there anything else you want to tell me:

Zoe Connor Dietitian - First appointment questionnaire last amended October 2014 – Page 1 of 1