Submitted by ahs-admin on Fri, 03/25/2022 - 03:49 You must have JavaScript enabled to use this form. First Name * Last Name * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Current Weight (lbs) * Height * Insurance Provider * Insurance ID Number * Do you have any food allergies, food intolerances or special diet needs, if yes, please specify * Vitamins, Minerals, Supplements that you currently take: * Previous Weight Loss Attempts * Check all that apply Increased exercise Decreased calories/portions Very low calorie diets Ketogenic diet Starvation Fad Diets Paleo Whole 30 Hospital/Clinic Based Diet Liquid Diet (Slimfast, Optifast, Medifast) Worked with Registered Dietitian Physician supervised diet Diabetes Education High protein/low carbohydrate Eating Disorder (anorexia, bulimia/purging) Commercial Diets (Weight Watchers, Jenny Craig, NutriSystems) Prescription Medications: HCG, Phentermine, Fen-Phen Xenical, Contrave, Belviq Other Other weight loss attempts Reasons Why Weight Loss Attempts Were Unsuccessful or Weight Was Re-gained * Check all that apply reached goal weight program/group ended moved from area cost impatient lost job program hard to follow/maintain lack of commitment mood worsened all or nothing thinking slow rate of weight loss lack of support weight plateau adverse reaction to medication self-sabotage unrealistic expectations lack of accountability persistent hunger eating disorder change/event in personal life not making healthy food choices eating too large of portions emotional eating frustration/discouragement with poor results for effort Other Other unsuccessful reason Current Meal Pattern and Intake (What do you eat on a typical day?) Breakfast Time of Day for Breakfast * Breakfast Food Eaten * Snack Time of Day for Snack * Snack Food Eaten * Lunch Time of Day for Lunch * Lunch Food Eaten * Snack Time of Day for other Snack * Other Snack Food Eaten * Dinner Time of Day for Dinner * Dinner Food Eaten * Snack Time of Day for late Snack * Late Snack Food Eaten * Middle of the Night Time of Day for late night * Late Night Food Eaten * Additional Comments about your meal patterns * Current Daily Fluid Intake (What you drink on a typical day) Water (in ounces) or Water (in bottles) Tea oz. Tea type Reg Decaf Sweet Unsweet Diet Herbal Green Coffee oz. Coffee type Reg Decaf Black Sugar No Cal Sweetener Milk Cream Diet Creamer Pop oz. Pop type Reg Diet With Caffeine De-Caff Milk oz. Milk type Skim 1% 2% Whole Soy Coconut/Almond (regular or light) Juice oz. Juice type Regular Low Calorie Diet/Calorie Free Sports Drink oz. Sports Drinks type Reg Zero Calorie Energy Drink oz. Energy drinks type Reg Diet Alcohol (amount and types) Current Eating Pattern Characteristics Do you eat when you are not hungry * Yes No What are your triggers Select all that apply stress upset mad/angry happy sad pleasure seeking depression anxiety boredom grazing social reasons habit schedule aroma taste visual cues (I see it, I want it) easily available watching TV or a movie other Other not hungry triggers Are there foods you typically eat? * Do you binge eat (or compulsive overeating)? * This is eating a much larger amount of food than normal and eaten in a relatively short period of time. This is often done alone, with a loss of control over the eating and sometimes you don’t remember. Yes No How often Triggers Emotional Not eating all day Isolation Other Other binge triggers Do you purge (vomit, exercise, or use laxatives) to lose weight? * Yes No How would you describe your hunger/eating habits? * I’m often not hungry I’m always hungry I skip meals I usually eat when I’m hungry How would you describe your portion sizes? * Large Medium Small How often do you clean your plate? * Always Sometimes Never Do you overeat? * Always Sometimes Never How fast do you usually eat? * Fast Moderate Slow Depends on the situation Do you chew your food to applesauce consistency? * Always Sometimes Never How often do you eat fast food? * Almost never 1-3 times a week 4-7 times a week More than 7 times a week How often do you eat sit down restaurant food? * Almost never 1-3 times a week 4-7 times a week More than 7 times a week Questions for the Dietitian? * Leave this field blank Submit