Client History

The purpose of this form is to securely collect your personal information, including your health & fitness history. Simply complete the requested information then click the submit button at the bottom of the form. This form submits encrypted information over a secure connection to ensure the safety of your personal health information.

*Fields with a star are required.

Personal

 

Explain your personal goal(s) and expectations in working with a dietitian

Health History

Have you been told that you have (check all that apply):

Do you have any complaints of the following:

For Females:

Socioeconomic History
Drug/Supplement History

List all medications and supplements you take, either prescribed or over-the-counter:

Explain any side effects you have noticed any side effects from taking these medications/supplements

Exercise History
Form Verification