Hello,
Your nutrition appointment has been scheduled for _____________________.
We look forward to making your Medical Nutrition Therapy appointment productive and satisfying. Spouses or
other individuals who can support you in your efforts are welcome to accompany you.
Remember To Bring:
Prior to your appointment, kindly complete the enclosed Nutrition Profile form and bring it with you to your
appointment.
Please Arrive On Time:
Traffic, parking, unfamiliarity with destination, and other circumstances frequently cause delay. We ask that you
make every effort to safely arrive on time for your appointment. An effective initial appointment requires a full
forty-five minutes of scheduled time. Late arrival significantly affects the quality of your appointment as well as
sessions for other individuals scheduled for the remainder of the day.
To check in:
Follow signs to Stanford Nutrition. Please press the call light in the waiting area to alert the dietitian of your arrival.
Please take a seat in the waiting area and the dietitian will call your name when ready.
Rescheduling or Canceling an Appointment:
Failing to appear, rescheduling and canceling appointments contributes to the increased costs of health care.
Please call 650-723-5440 as soon as you know that you need to cancel or reschedule your appointment.
Jessica Shipley, MS, RD
Clinic Nutritionist
Hoover Pavilion
211 Quarry Road
Suite 207, 2nd Floor
Palo Alto, CA 94304
Phone: 650-723-5440 or 650-736-1806
DIRECTIONS TO 211 Quarry Road:
From 101 North or South
§
Take the Embarcadero Road/West exit.
§
Follow Embarcadero Road for about two miles.
§
Turn right on El Camino Real and left on Quarry Road.
§
The Hoover Pavilion will be on your left.
§
Parking is available in the Hoover Garage PS9
From 280 North or South
§
Take the Sand Hill Road exit and head east.
§
Turn right on Arboretum Road and left on Quarry Road.
§
The Hoover Pavilion will be on your right.
§
Parking is available in the Hoover Garage PS9
ONCE YOU HAVE ARRIVED AT THE HOOVER
PAVILION:
• Enter building through the main entrance
and take the elevators to the 2nd floor.
•
Turn right out of the elevators and walk to the
very end of the hallway. Follow signs to
“Stanford Nutrition.”
• Press the call light to alert the dietitian of
your arrival.
• Please have a seat in the waiting area.
Stanford Hospital & Clinics Nutrition Profile
Name: ____________________________________________________ Date: ____________________________
(Last)
(First)
Reason for Nutrition Consultation: _______________________________________________________________
Occupation: _________________________________________________________________________________
Age: _____
Height: _____ft._____ in.
Current Weight: _____ lbs
What is a realistic, healthy weight for yourself? _________________________________________________
How has your weight changed in the past two years? _____________________________________________
Have you ever had: High Cholesterol? Yes/No, High Blood Sugar? Yes/No, High Blood Pressure? Yes/No
Food Allergies?
Yes
No
If yes, list the food allergies and the allergic reaction _________________________________________________
List any medications, vitamins, minerals, herbs and nutritional supplements that you take:
____________________________________________________________________________________________
____________________________________________________________________________________________
Which meal do you eat the most at?
Breakfast
Lunch
Dinner
# of meals you eat per day? _______________ # of snacks you eat per day, if any? ________________________
What percent of meals that you eat are prepared at your home? _________________________________________
How often in a week do you dine out? _____________________________________________________________
Who does the grocery shopping at home? __________________________________________________________
Who prepares your meals at home? _______________________________________________________________
Do you drink alcohol?
Yes
No
If yes, how much in a week? ______________________________________
What kind of beverages do you normally drink? _____________________________________________________
What types of exercise do you do regularly and how much time each week do you spend doing them?
Activity or Exercise
Times per Week
Minutes per Activity
Physical limitations?___________________________________________________________________________
Please record your food intake for two typical days.
Food Intake Record
Date:
Meal
Breakfast:
Food
Amount Eaten
Time:
Snacks:
Time:
Lunch:
Time:
Snacks:
Time:
Dinner:
Time:
Snacks:
Time:
Exercise:
Type of Exercise:
Number of Minutes:
Please record your food intake for two typical days.
Food Intake Record
Date:
Meal
Breakfast:
Food
Amount Eaten
Time:
Snacks:
Time:
Lunch:
Time:
Snacks:
Time:
Dinner:
Time:
Snacks:
Time:
Exercise:
Type of Exercise:
Number of Minutes: