Hannah Limpert Warner, RD, LDN
Demographic Information
Please enter your current details in the fields below:
Address: City:
State: Zip code:
Primary phone number:
Date of Birth:
Email address:
Preferred contact method: Email- No Phone- No
Can we leave a message: Yes- No-
Fill out only if it applies:
Primary insurance name:
Type of plan: Phone number:
Insured's name: Relationship:
Insured address: (if different from yours)
Membership ID/Subscriber ID number: Group ID number
How did you hear of me?
Reason for visit:
Date of birth:
Weight History
Please enter your current weight and height as well as informationabout whatyour weight was likethe past.
Weight: lbs ()
Height/length: ft in(in)
Previous nutrition consultation:Yes - No - Details of visit / what did you want to get out of those sessions?:
Have you hadRecent Weight gain: Amount of weight gain: Time frame (how long have you had this weight put on):
Recent weight loss: Amount of loss & What was the time from of loosing that weight:
Lowest adult weight: Age:
Highest adult weight: Age:
Marital status:
Highest level of education:
Occupation: Retired:
Work hours:
Members of household:
General Health Information
Please enter your insurance details, primary care physician and other important healthcare providers:
Primary physician name: Phone number:
Address:
Date of last physical:
Do you see a therapist? If so, why and how long have you been going?:
Other important healthcare providers you see:
Family History
Do you have a family history of the following? Please check all that apply.
- Cancer / - High blood cholesterol / - Liver disease- Diabetes / - High blood pressure / - Thyroid disease
- Heart disease / - Kidney disease / - Obesity
Other Pertinent Medical History:
Medical History
Please select if you have been diagnosed with or currently have, any of the following medical conditions:
Past surgeries / hospitalizations:
Medical History Details: (blood pressure, HA1C, etc.)
Details:
-Anemia / -Fibromyalgia / -Lung disease
Details:
-Anxiety or panic attacks / -Gallbladder disease / gallstones / -Metabolic syndrome
-Arthritis / -Gout / -Memory problems
Details:
-Asthma / -Hearing problems / - Myocardial infarction / angina
-Autoimmune condition / -Headaches / migraines / -Osteoporosis / osteopenia
-Back pain / -Hay fever / -PMS
-Bronchitis / -Heartburn / -Polycystic ovary syndrome
-Cancer
Type: / -Heart disease
Details: / -Pneumonia
-Depression / -Hemorrhoids / -Pre-diabetes
-Diabetes
Type: / -Hepatitis / -Prostate problems
-Drug abuse / -High cholesterol levels / -Psychiatric conditions
Details:
-Diverticulitis / -Hypertension (high blood pressure) / -Sinusitis
-Dry itchy skin, rashes, dermatitis / -HIV/AIDS / -Sleep apnea
-Eating disorder
Details: / -IBD (Crohn’s or ulcerative colitis) / -Stomach ulcers
-Eczema / -Irritable bowel syndrome (IBS) / -Stroke
-Epilepsy, convulsions, seizures / -Joint pain / joint replacement
Details:
-Kidney disease
Details: / -Urinary tract infection
-Eye disease
Details: / -Kidney stones / -Vitamin D deficiency
What do you feel your current challenges are and what will you do to overcome them?:.
Gastrointestinal Symptoms
Please select if you regularly experience any of the following:
-Abdominal bloating / -Diarrhea / -Nausea-Abdominal cramping / -Early satiety / -Pain on swallowing
-Abdominal distension / -Excessive appetite / -Poor appetite
-Abdominal pain / -Excessive belching / -Retching
-Acid reflux / -Excessive wind / -Vomiting
- Bulky stools / -Heart burn / Other:
-Constipation / -Liquid stools / Other:
Medication & Supplements
Please list all prescription and over-the-counter medications, vitamin, mineral and nutritional supplements, herbs/botanicals and diet aids you are currently taking.
Please list any new medications, reason for taking, and dose and frequency
Physical Activity
Do youregularly participate in physical activity/exercise? If the answer is yesplease describe below. If you are unable to exercise, please provide details.
Physical activity / exercise: Yes- No- Type:
Session duration:
Frequency:
Barriers to exercising: Yes- No- Details:
Alcohol & Smoking
Please describe below your history of alcohol intake within the past 12 months.Please, also completeyour current and past smoking status.
Frequency of alcohol intake: Type:
Quantity:
Current smoking status: Amount:
Past smoking status: Amount:
Stress
On a scale from 1-10 with 10 being the highest, how would you rate your daily level of stress?
Stress rating (0 = no stress & 10 = extreme stress): How do you deal with your stress?:
Sleep
Based on yoursleep habits during the past month only, how many hours of sleep, on average, do your get on week nights and weekend nights?
Amount of sleep on week nights:
Amount ofsleep on weekend nights:
Over the past month have any of the folling of the following? Please select those that apply to you.
Food Recall
Please complete my 2 Day Food Record for everything you eat and drink. Please be honest when writing down this information. Stay with your typical eating patterns. The more specific you are about product brands, names of restaurants, type of bread (wheat vs. white, etc.), type of milk (whole vs. skim, etc.) and other items you eat, the better.Every detail, such as portion size (teaspoon, tablespoon, cup, etc.), is important. For those unusual items prepared at home, please attach the recipe.At the bottom of this form please be sure to give detail on 3 typical breakfasts, lunches, and dinners. Thanks!
Date:
Meal / Time / Food/Beverages ConsumedBreakfast
Snack
Lunch
Snack
Evening meal
Evening snack
What other snacks do you eat?
What are all the beverages you drink?
Date:
Meal / Time / Food/Beverages ConsumedBreakfast
Snack
Lunch
Snack
Evening meal
Evening snack
Other snacks
Other beverages
Diet History
Please answer the following questions about your diet and eating habits.
Food likes (please name all foods you really like and would want on your meal plan):
Food dislikes: i.e.what fruits do you NOT like? Vegetables that you do NOT like? Starches/Carbs/Grains you do NOT like? Fats such as avocado, hummus, mayo, sour cream, cream cheese, etc. do you NOT like? What dairy foods do you NOT like? What meats/meat alternatives do you NOT like? Please list them all here:
Food allergies:
Dietary restrictions / limitations:
Food intolerances and sensitivities:
Other allergies:
Grocery shopping:
Meal preparation andcooking:
Food Frequency
On average, how often do you eat the following foods? When you eat each food, what is your average serving size? For example 2 eggs, 1 cup of milk, 2 teaspoons of sugar, 1/2 a cup of cooked rice, 16-ounce of soda.
Food / Frequency / Amount (serving size)Meat
Seafood and fish
Poultry
Eggs
Legumes i.e. beans, lentils
Nuts and nut butter (e.g. peanut butter)
Vegetables,salad
Milk
Yogurt
Cheese
Breakfast cereal
Bread,rolls,wraps
Crackers, crisp bread
Pasta, noodles
Rice
Other grain foods
Fruit, canned fruit,dried fruit
Fruit juice
Fats,oils
Dressings, sauces, ketchup,mayo, condiments
Added sugar e.g. addsugar to coffee
Added salt e.g. add salt to meal or cooking
Cakes, cookies, pastries
Chocolate, candy
Potato chips, savory snacks
Ice cream, mousse, dairy snacks
Soda, cordial, other sweetened beverages
Take-out and convenience food
Alcohol
Any additional comments on the foods/beverages in your diet that I should know about in considering your meal plan?:
Please list at least 3 Breakfast, Lunch, Dinners, and Snacks that you like. Please list 3 Meals for Breakfast, Lunch, and Dinner you enjoy: