Csulb Nutrition Counseling - Confidential Intake Form

CSULB NUTRITION COUNSELING - CONFIDENTIAL INTAKE FORM

Name:

Today’sDate:

StudentID#

CellPhone:

Occupation:

Date of Birth:

Gender:Male Female Transgender Age:

Height:Weight:

Referredby:Self-referredClinicianInstructorFriendOther,please specify:

Reason forvisit:

General nutrition/bettereatinghabits

Diet for weight loss

Diet for weightgain

Sports nutrition

EatingDisorder

Anemia

Constipation

High Cholesterol

Hypertension(high blood pressure)

Hypoglycemia (low blood sugar)

Other (specify):

Areyou under aclinician’s care for a condition orillness?

Ifyes, forwhichcondition/illness?

Do you have certain dietary practices (i.e. vegan, vegetarian, gluten-free, etc.)? ______

Haveyou been diagnosedbyaclinician for a nutrition-relatedproblem (such asanemia,highcholesterol,hypoglycemia,gastrointestinal problem, thyroid disorder, etc.)?

Ifyes, please specify:

Ifyoubelieve you havea nutrition-relatedproblemor metabolic disorder, youmustsee aclinicianforanaccurate diagnosis.

What if anything,haveyou donepreviouslyto manageyour nutrition-related concerns?

Currentmedications:______

Vitamins/minerals/herbalsupplements: ______

Reasons for taking: ______

Please turn the pageover andcontinue

Exercise:

Doyouexercise? ______If not, why?

Types of ExerciseHow Often? (times per wk.) For how long? (hrs./mins.)

Average time spent sitting (i.e., screen time, work, and commute)? ______

Average hours of sleep per night? ______

Typical daily stress level: (circle one) High Average Low

Ability to manage stress: (circle one) Excellent Okay Poor

Food Choice Inventory:

Doyou haveanyethnicallyspecificfoodpreferences(i.e.,Chinese,Filipino,Mexican,etc.)?

Yes NoIfyes,specify:

Fooddislikes:

Foodallergies/intolerances:

MealPlanning:

Who plansyour meals?Who cooks? Who shops? Isalist used?

DiningOut:

How often doyou eat out/week?Doyoueatat:

Fast food restaurants? / Yes / No / Times perweek:
Other Restaurants? / Yes / No / Times perweek:
Otherpeople’shomes? / Yes / No / Times perweek:

Beverages:

Doyou drink alcohol?Whattype?Weekly amount?Doyou drink coffee/tea drinks, i.e. Frappuccino, Mocha, etc? ___Daily amount? Doyou drink water? Dailyamount?

Doyou drink soda? ______Dailyamount?______Regular: _____Diet:

What otherbeverages?Daily amount?

Return form to the HRC receptionist upon completion. Thank you!

Please note: For your scheduled appointment, please arrive on time. If you are more than 15 minutes late, your appointment will be cancelled. If you are a “No Show” for your appointment, you will only be allowed to reschedule the appointment one more time.

Initials:_____Revised2/17(hb)