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Preferred Name
Date of Birth
Gender/preferred pronoun
City, State, Zip Code
Employee address
Please list previous occupations
Home number
Cell number
Work number
text number
Name, phone #, relationship
What goals do you have for your visit at the office/clinic today?
Who is your Primary Care Provider?
Phone number of Primary Care Provider
Please list other providers/specialists involved in your care and their clinic phone number:
If you are seeking adjunctive cancer support, who is your oncologist? Oncologist’s name & phone number:
When was your last physical?
When did you last have bloodwork?
If Yes, how many drinks per week?
If Yes, how many cups per week?
How often do you use cannabis in a given week? In what forms?
Other drug usage, past or present:
amount/packs per day. How long? Quit date.
If yes, what are their ages?
If yes, please describe type of exercise and how often.

Preferred Name
Mother’s Name (minors only)
Mother’s Date of Birth (required)
Father’s Name (minors only)
Father’s Date of Birth (required)
Other Legal Guardian Name
Relationship to Patient
Patient’s Date of Birth (required)
Patient Signature (18 and older) , Date
Parent/Guardian Signature , Date
What is your preferred language when speaking with your Registered Dietitian Nutritionist?

Date of birth
Family member with allergies
Family member with anemia
Family member with anxiety
Family member with arthritis
Family member with asthma
Family member with blood transfusion
Family member with cancer
Family member with cataracts
Family member with congestive heart failure
Family member with clotting disorder
Family member with COPD
Family member with depression
Family member with diabetes
Family member with emphysema
Family member with GERD
Family member with glaucoma
Family member with heart attack
Family member with heart murmur
Family member with HIV/AIDS
Family member with hypertension
Family member with irritable bowel syndrome
Family member with kidney disease
Family member with meningitis
Family member with nerve/muscle disease
Family member with osteoporosis
Family member with Parkinson’s/Alzheimer’s
Family member with seizures
Family member with sickle cell anemia
Family member with stroke
Family member with substance abuse
Family member with thyroid disease
Family member with tuberculosis
Family member with ulcers
If yes, please explain
Include name of medication/supplements; Strength; Directions
self or family
Type of surgery/reason for hospitalization: Date

Date of birth
How often do you have a bowel movement? ( how many times per day/week)
When was the last dose of antibiotics taken?
Have you traveled outside the country? If so, where and when?
Have you ever had food poisoning? If so, when?
Please list:
If Yes, please describe.
If Yes, please describe.
Date or age of when menstruation began
Please describe PMS symptoms
How many pregnancies have you had? Age at conception?
How many times did you give birth? Age when you conceived?
Do you have any skeletal or muscular pain? If so, where?
Rate the current intensity of your pain on a scale of 1-10, with 10 being the most intense.
If Yes, please list.
With whom do you live?
What do you dedicate yourself to (work, school, parenting, significant hobbies…)?
What are your major stressors?
What do you do to cope with stress?
Patient/Guardian (Print Name) & Date.
Patient/Guardian Signature, & Date of birth
Reviewed by RDN, Date

Initial after reading and comprehending
Name of physician
Signature and date
Signature and date
Signature and date

Signature & date
Signature and date
Signature and date

Initial after reading and comprehending
Signature and date
Thank you for working with us to ensure that services are provided to all our clients/patients in the best possible way.