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Nutrition Referral Form
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Home Page
Specialities
Blogs
Fun Quizzes
About Me
Schedule an Appointment
Contact Form
Nutrition Referral Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Preferred Name
Date of Birth
Gender/preferred pronoun
Address
City, State, Zip Code
Have you ever lived on/near a farm/agriculture?
Yes
No
Have you vacationed, worked, or lived out of the country?
Yes
No
Email
*
Are you currently employed?
Yes
No
Employee address
Occupation
Please list previous occupations
Phone
Home number
Cell number
Work number
text number
Best way to reach you
email
home number
cell number
work number
text
Confidential voicemails OK?
Yes
No
Emergency Contact
Name, phone #, relationship
A note to patients: Please compete this questionnaire as thoroughly as possible in order to aid the Registered Dietitian Nutritionist (RD/RDN) in their assessment, recommendations and nutritional diagnosis. This is a confidential record of your nutritional assessment and recommendations and will not be released, except if you have provided us with written authorization. Thank you for your help.
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?
Please indicate the type of care you are seeking
Prevention management of my health
Supportive management of my health
Adjunctive care for my health
One time advice for my health
I don’t know at this time
Have you ever consulted a Registered Dietitian Nutritionist or Counselor before?
Yes
No
If YES, please check which type of practitioner you've previously consulted with
Registered Dietitian Nutritionist
Nutritionist
Health Coach
Other
In general, would you say your health today is:
Excellent
Very Good
Good
Fair
Poor
SOCIAL HISTORY
Do you consume alcohol?
Yes
No
If Yes, how many drinks per week?
Do you consume coffee?
Yes
No
If Yes, how many cups per week?
Do you use cannibis?
Yes
No
If yes, for
medicinal use
recreation use
both
How often do you use cannabis in a given week? In what forms?
Other drug usage, past or present:
Current or past tobacco use:
amount/packs per day. How long? Quit date.
Do you have children?
Yes
No
If yes, what are their ages?
Do you exercise regularly?
Yes
No
If yes, please describe type of exercise and how often.
Are you homeless or do you live in temporary living conditions?
Yes
No
Do you have issues with food security?
Yes
No
Name
Submit
,
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Name
*
First
Last
Preferred Name
PARENT/GUARDIAN INFORMATION (To be filled out if patient is a minor, or if someone other than the patient is medically and financially responsible for the patient.
Mother’s Name (minors only)
Legal Guardian?
Yes
No
Mother’s Date of Birth (required)
Father’s Name (minors only)
Legal Guardian?
Yes
No
Father’s Date of Birth (required)
Other Legal Guardian Name
Relationship to Patient
Patient’s Date of Birth (required)
I hereby acknowledge that I am the guarantor and financially responsible for payment of all services rendered, and that I am subject to all terms on the financial consent form.
Patient Signature (18 and older) , Date
Parent/Guardian Signature , Date
DEMOGRAPHIC DATA COLLECTION. RDadvantage is committed to providing quality care for all patients. We are asking you to provide your marital status; your racial and ethnic background; the language you prefer to use when speaking with your doctor; and whether you are or were military. Your answers are both voluntary and private. Thank you for your cooperation.
What is your marital status?
Single
Married
Significant Other
Widowed
Do you consider yourself Hispanic or Latino? Please check one:
I AM Hispanic or Latino
I am NOT Hispanic or Latino
I don’t know
Decline to answer
Which category best describes your race? You may check one or more:
White or Caucasian
Black or African American
Asian
American Indian
Alaskan Native
Native Hawaiian or other Pacific Islander
Other race
I don’t know
Decline to answer
What is your preferred language when speaking with your Registered Dietitian Nutritionist?
Do you need an interpreter?
Yes
No
Are you active military or veteran?
Yes
No
Decline to answer
How did you hear about me?
Email
Submit
,
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Name
*
First
Last
Date of birth
Please check box to indicate if you or family member has ever had the following conditions. If condition does not apply, check n/a. Please indicate which relative has the condition. (i.e.- self, mother, father, sibling, maternal grandmother (MGM), maternal grandfather (MGF), paternal grandmother (PGM), paternal grandfather (PGF)
Allergies
yes
no
n/a
Family member with allergies
Anemia
yes
no
n/a
Family member with anemia
Anxiety
yes
no
n/a
Family member with anxiety
Arthritis
yes
no
n/a
Family member with arthritis
Asthma
yes
no
n/a
Family member with asthma
Blood transfusion
yes
no
n/a
Family member with blood transfusion
Cancer
yes
no
n/a
Family member with cancer
Cataracts
yes
no
n/a
Family member with cataracts
Congestive Heart Failure
yes
no
n/a
Family member with congestive heart failure
Clotting disorder
yes
no
n/a
Family member with clotting disorder
COPD
yes
no
n/a
Family member with COPD
Depression
yes
no
n/a
Family member with depression
Diabetes
yes
no
n/a
Family member with diabetes
Emphysema
yes
no
n/a
Family member with emphysema
GERD
yes
no
n/a
Family member with GERD
Glaucoma
yes
no
n/a
Family member with glaucoma
Heart Attack
yes
no
n/a
Family member with heart attack
Heart murmur
yes
no
n/a
Family member with heart murmur
HIV/AIDS
yes
no
n/a
Family member with HIV/AIDS
Hypertension
yes
no
n/a
Family member with hypertension
Irritable Bowel Syndrome
yes
no
n/a
Family member with irritable bowel syndrome
Kidney Disease
yes
no
n/a
Family member with kidney disease
Meningitis
yes
no
n/a
Family member with meningitis
Nerve/muscle disease
yes
no
n/a
Family member with nerve/muscle disease
Osteoporosis
yes
no
n/a
Family member with osteoporosis
Parkinson's/Alzheimer's
yes
no
n/a
Family member with Parkinson’s/Alzheimer’s
Seizures
yes
no
n/a
Family member with seizures
Sickle cell anemia
yes
no
n/a
Family member with sickle cell anemia
Stroke
yes
no
n/a
Family member with stroke
Substance Abuse
yes
no
n/a
Family member with substance abuse
Thyroid disease
yes
no
n/a
Family member with thyroid disease
Tuberculosis
yes
no
n/a
Family member with tuberculosis
Ulcers
yes
no
n/a
Family member with ulcers
medication allergies or any allergic reactions to anything else
yes
no
n/a
If yes, please explain
Do you have an Epi Pen for severe allergic reactions?
yes
no
n/a
Other
Please list all mediations and supplements you are taking including prescriptions, over-the-counter medications, vitamins, minerals, herbs and homeopathic remedies.
Include name of medication/supplements; Strength; Directions
Description of other pertinent medical history
self or family
Were you born via:
Vaginal delivery
C-section
Were you:
Breastfed
formula fed
both
Please list any surgeries or hospital stays you have had and their approximate date/year:
Type of surgery/reason for hospitalization: Date
Phone
Submit
,
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Name
*
First
Last
Date of birth
DIGESTION – please check any issues you have with digestive function:
none
gas, bloating, flatulence, burping
abdominal pain or cramping
How often do you have a bowel movement? ( how many times per day/week)
Please check all that apply about your bowel movements:
Difficult to pass
Loose
Diarrhea
Contain undigested food
Fatty or oily
Incomplete
Small and hard
Contains blood
Dark in color/tar-like
Formed
Easy to pass
Feels complete
How often have you taken antibiotics in your life:
Never
Rarely
Sometimes
Often
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 check any that apply to you:
Celiac disease
Crohn’s disease
Difficulty chewing
Difficulty swallowing
Diverticulosis or diverticulitis
Gingivitis
Heartburn or GERD
Hiatal hernia
Irritable bowel syndrome (IBS)
Missing teeth
Root canals
Silver amalgams
Oral allergy syndrome
Swollen gums
Ulcerative colitis
IMMUNE DEFENSE AND REPAIR. How often do you get sick?
Rarely
Sometimes
Often
Do you feel you get sick more than others around you?
Yes
No
Do you have any chronic inflammatory conditions (arthritis, autoimmune disease, eczema…)?
Please list:
Do you heal quickly after injury or surgery?
Yes
No
Unsure
SLEEP. Do you have any difficulty sleeping?
Yes
No
Please check any that apply to you:
Trouble falling asleep
Trouble staying asleep/wake frequently
Night terrors
Difficulty swallowing
Snoring
Stop breathing at night
Use a C-PAP machine
Dream
Feel tired in the morning
Have trouble waking up
Feel rested in the morning
Sleep well generally
CIRCULATION. Do you have swelling in any part of your body?
Yes
No
If Yes, please describe.
Please check all that applies:
Varicose veins
Spider veins
Cold ands and feet
BIOTRANSFORMATION AND ELIMINATION. Are you routinely exposed to any chemicals through your living situation, recreation or work (solvents, pesticides, cigarette smoke…)?
Yes
No
Unsure
If Yes, please describe.
Check all that you are sensitive to:
Caffeine
Perfume
Cigarette smoke
Other
Check all that apply to you:
Lived on a farm or where any agricultural or insect-controlling chemicals were
Lived in a home built prior to 1975
Ate fish, mollusks or crustaceans more than twice a week
Worked in any industry where you could smell chemicals
Have had any significant exposure to chemicals you know of
Worked with any toxic metal including dentistry
Lived or worked in an area that was or became a Superfund site
Lived or worked where you could see or smell any burning of fuel, metal, rock or wood
HORMONE BALANCE. Please check all that apply to you:
Acne
Anxiety
Crave sugar or salt
Depression
Difficulty concentrating
Do not feel rested in the morning
Dry skin
Feel unusually cold or hot
Forgetfulness or memory problems
Hypoglycemia
Hyperglycemia (Diabetes or insulin resistance)
HORMONE BALANCE. Females only:
PMS
Unwanted facial hair
Infertility
Menopause
Fibroids
Endometriosis
Blood clots
Varicose veins
Date or age of when menstruation began
Please describe PMS symptoms
Pregnancy
How many pregnancies have you had? Age at conception?
How many times did you give birth? Age when you conceived?
STRUCTURAL INTEGRITY. Do you bruise easily?
Yes
No
Do you get headaches?
No
Rarely
Sometimes
Frequently
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.
SPIRITUAL/EMOTIONAL/SOCIAL. Do you have a spiritual practice that you follow?
Yes
No
If Yes, please list.
Do you have a good support system in your life (friends, loved ones…)?
Fair
Good
Excellent
With whom do you live?
What do you dedicate yourself to (work, school, parenting, significant hobbies…)?
How would you rate your stress level overall?
Low
Medium
High
Extreme
What are your major stressors?
What do you do to cope with stress?
SIGNATURES
Patient/Guardian (Print Name) & Date.
Patient/Guardian Signature, & Date of birth
Reviewed by RDN, Date
Comment
Submit
,
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METHODS, PROCEDURES, AND THERAPEUTIC APPROACHES: RDS scope of practice focuses on food and nutrition and related services developed, directed, and provided by RDNs to protect the public, community, and populations, enhance health and well-bing of patients/clients, and deliver quality products, programs, and services including Medical Nutrition Therapy, herbal medicine, natural medicine, dietary advice, and therapeutic nutritional counseling.
Initial after reading and comprehending
I understand that California State law does not authorize RDNs to treat me for an cancer or malignancy and that I am required to be under the care of a medial doctor or osteopathic physician while receiving care at RDadvantage LLC. I am currently under the care of:
Name of physician
I recognize that I am here for supportive therapies only.
Signature and date
I understand that a hands-on physical exam to look for deficiencies, toxicities, or any other signs of malnutrition may by conducted. The Registered Dietitian Nutritionist may perform general dietary advice and therapeutic nutritional counseling. Dietary advice and medical nutrition therapy is not a diagnosis. I understand that a Registered Dietitian Nutritionist is not a substitute for asking my doctor for help. I will consult with my doctor when making dietary changes.
Signature and date
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by RDadvantage LLC or its personnel regarding assessment , recommendation, or improvement of my condition. I understand that a record will be kept of the health services provided to me. I HEREBY ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED.
Signature and date
Email
Submit
,
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What you should know: By signing this agreement you have agreed to pay for your services by self-pay. You many ask your insurance company about using out-of-network benefits (super billing) that may or may not cover for none or some of the services you receive. If you are not sure about your out-of-network coverage, please ask your insurance company. If insurance doesn't cover any costs of services, I acknowledge that I am financially responsible for services rendered.
Signature & date
NONPAYMENT. If you have not paid your bills within 30 days after receiving your final notice, you will be turned over to collection agency. You will be responsible for any collection agency feed that apply. If you have large unpaid balanced and make no arrangement or payments, you may by reported to a credit bureau and denied additional services at RDadvantage LLC.
Signature and date
INSURANCE BILLING. Non-contracted. If your insurance plan is not contracted with RDadvantage LLC, we will provide a superbill for you to turn into your insurance. You are responsible for the full cost of care upfront whether or not your insurance will pay pay out-of-network coverage for services. We expect full payment at the time of the service.
RETURNED CHECKS. RDadvantage LLC charges $28 for any returned checks. Questions? Please contact RDadvantage LLC at 818-335-9457 if you have any questions about anything in our policy.
Signature and date
Website
Submit
,
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Welcome to RDadvantage LLC. We are glad you have made an appointment for yourself or a family member. To provide you with high-quality care, it is important for you to keep your scheduled appointment with the RDN. Valuable time has been reserved for you or your family member. A missed appointment or late cancellation results in lost time that could have been given to another person wanting to receive care.
Initial after reading and comprehending
patients arriving more than 15 minutes late to their appointment will be subject to the providers’ discretion as to whether they can be seen. Late arrivals may also be subject to an abbreviated visit.
If a patient cannot be seen, or is more than 20 minutes late for a scheduled visit, it will automatically be considered a no show.
If you need to cancel or reschedule your appointment, please call 24 hours in advance. You may also leave a message at our office (818) 335-9457. Every late cancel/no-show will be recorded in your chart. Multiple late cancels and no-shows can end your ability to make advanced appointments or receive care at RDadvantage LLC.
Signature and date
We realize that an emergency may occur and/or you may not be able to notify us. We will discuss that situation with you when it happens:
After 1 late Cancel/No Show: You will be reminded of our Late Cancel/No Show policy
After 2 Late Cancels/No Shows: There will be a charge of $40 for appointments missed or late cancelled.
After 3 Late Cancels/No Shows: Advanced scheduling privileges will be suspended for three months. You can still be seen on a same-day scheduling basis only, depending on RDN’s availability. We cannot guarantee that you will be seen
Thank you for working with us to ensure that services are provided to all our clients/patients in the best possible way.
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