TRANSCEND NUTRITION COUNSELING, LLC
2828 YORKVIEW COURT, CHARLOTTE, NC 28270
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
PATIENT INFORMATION
First name _________________________ Last name _________________________
Address ______________________________________________________________
City _____________________________ State _________ Zip Code _____________
Gender M
F Date of birth ____/_____/_____ Age _______ SSN ____-____-_____
Home phone number (___)_____-_______
Preferred contact number? Y
N
Can we leave a voicemail? Y
N
Can we leave a voicemail? Y
N
Cell phone number (___)_____-_______
Preferred contact number? Y
N
Email address ___________________________@__________________.__________
If patient is a child under age of 18 or dependent, list Parent/Guardian information:
First name _________________________ Last name _________________________
SSN ____-____-_____ Date of birth ____/_____/_____
Home phone number (___)_____-_______
Preferred contact number? Y
N
Can we leave a voicemail? Y
N
Can we leave a voicemail? Y
N
Cell phone number (___)_____-_______
Preferred contact number? Y
N
Primary Care Physician ____________________ Phone number (___)_____-_______
Who referred you? _____________________________________
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TRANSCEND NUTRITION COUNSELING, LLC
2828 YORKVIEW COURT, CHARLOTTE, NC 28270
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
NUTRITION HISTORY
Reason for nutrition consult _______________________________________________ Height __________
Current weight __________
Usual weight __________
Max adult weight __________ Min adult weight __________ Goal weight __________
BIA _______ Biceps _______ Chest _______ Waist _______ Hips _______ BMI _____
Please check all that describes you:
!I am motivated to change so that my clothes will fit better
!I am motivated to change so that I can feel better
!I am motivated to change for health reasons and/or a medical diagnosis
!My spouse encouraged me to schedule an appointment
!My doctor encouraged me to schedule an appointment
!This appointment is required as part of a pre-op program
!I am motivated to change so that my family can eat healthier meals
In the past for weight loss I have tried:
!Weight Watchers
!Paleo
!Exercise
!Surgery: ________________
!Atkins
!____________
!Medication: ___________________ !21-Day Fix
!____________
Prior weight loss methods have been successful / unsuccessful because:
___________________________________________________________
___________________________________________________________
Current medications Dose/day
Vitamins, minerals,
__________________________
_____________
herbs, supplements
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
__________________________
_____________
Dose/day
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TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
PAST MEDICAL HISTORY
Cardiopulmonary
! Asthma
! COPD
! Emphysema
! Heart attack
! Heart disease
! Heart murmur
! High blood pressure
! High cholesterol
! Sleep apnea
Gastrointestinal
! Barrett’s esophagus
! Cirrhosis
! Diverticulitis
! Diverticulosis
! Hepatitis
! Hiatal hernia
! Irritable bowel syndrome
! Inflammatory bowel disease
! Liver disease
! Pancreatitis
! Reflux
Hematology
! Anemia
! Bleeding disorders
Endocrine/Renal
! Type I Diabetes
! Type II Diabetes
! Hyperthyroid
! Hypothyroid
! Insulin resistance
! Kidney disease
! Kidney failure
! Polycystic ovarian syndrome (PCOS)
! Metabolic syndrome
Muscular/Skeletal
! Arthritis
! Fibromyalgia
! Gout
! Osteoporosis
! Rheumatoid arthritis
Neurological
! Anxiety
! Bipolar
! Depression
! Migraines
! Seizures
! Stroke
Cancer
! Breast
! Colon
! Gastric
! Leukemia
! Lymphoma
! Pancreatic
! Prostate
Allergies
! Wheat
! Eggs
! Dairy
! Gluten
! Tree nuts
! Peanuts
! Soy
Drug use
! Tobacco
Check all that apply
! Cigarettes
! Snuff
! Dip
! Patches
! Gum
Frequency _______ per week
! Alcohol
Check all that apply
! Alcohol
! Wine
! Beer
! Liquor
Frequency _______ per week
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TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
LIFESTYLE INFORMATION
Sleep routine
Weekdays __________ hours per night
Occupation ___________________
Weekends __________ hours per night
Hours per week __________
Household make up
Name
Relationship
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Who plans meals, grocery shops, prepares and cooks meals? ___________________
Where does the household do the majority of grocery shopping?
___________________________
___________________________
Hobbies
________________________
________________________
________________________
________________________
Exercise Regimen
Do you regularly exercise?
Y
Indicate exercises that you enjoy/participate in regularly:
N
Exercise
Cardiovascular (run, walk, elliptical)
Minutes per week
________________
Strength training (weights or body weight)
________________
Yoga / Pilates
________________
Group Classes (Zumba, Body Pump, Cycle, Other)
________________
Circuit training (Cross Fit, 9 Rounds)
________________
Swimming
________________
Where do you typically exercise?
! Gym, which one? __________________________________
! Home / neighborhood, equipment availability? ______________________________
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TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
Meal intake
How often do you regularly eat the following meals?
Breakfast __________ out of 7 days
Lunch __________ out of 7 days
Dinner __________ out of 7 days
Snacks __________out of 7 days
How often do you eat food from restaurants (including take out)?
Breakfast __________ out of 7 days
Lunch __________ out of 7 days
Dinner __________ out of 7 days
What restaurants do you frequent?
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Drink intake
Indicate all that apply:
! Water
! Coffee
(caffeinated/decaffeinated)
! Iced coffee, frapppucino, latte (caffeinated/decaffeinated)
! Hot tea
(caffeinated/decaffeinated)
! Iced tea
(sweet/unsweetened)
! Soda
(regular/diet)
! Milk
(Skim, 1%, 2%, whole)
! Juice
(fruit/vegetable)
! Sugar-free drinks (Crystal Light, Vitamin Water, Sobe Zero, Propel)
! Other
_________________________________________
Current Diet
Indicate all that apply:
! Diabetic
! Low fat, low
cholesterol, low
saturated fat
! Gluten-free
! Low sodium
! Caloric-restricted:
______ per day
! No pork/red meat
! Lactose-free
Cups per day
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
! Vegetarian
! Vegan
!______________
! _____________
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TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
FOOD PREFERENCES LIST—Check the foods you ENJOY or are WILLING to try.
Carbohydrates-- Provide Energy- Fuels the Body
Proteins-- Sustain Energy- Builds the Body
Grains
Fruits
Starchy Vegetables
Meat
Other Proteins
! Oats
! Apricots
! Corn
! Beef
! Eggs
! Wheat
! Apples
! Lima
! Pork
! 100%
! Barley
! Bananas
! Peas
! Quinoa
! Blackberries
! Potatoes
Poultry
! Cheese
! Cereal
! Blueberries
! Sweet
! Turkey
! Cottage
! Rice
! Cantaloupe
! Butternut
Squash
! Bread
! Cherries
! Spaghetti
Squash
! Pasta
! Grapes
! Acorn
! Tortillas
! Kiwi
! Pitas
! Bagels
! English
Muffin
Beans
! Egg
Potatoes
Squash
! Chicken
! Meat
provide a combination of protein and
! Honeydew
! Tuna
carbohydrates
! Mangoes
! Tilapia
! Strawberries
! Grouper
! Watermelon
! Muffins
! Shellfish
! Waffles
Processed Meats
! Pancakes
! Bacon
! Grits
! Sausage
! Hot
Carbohydrate + Protein
Dairy
Soy
! Milk
! Edamame
! Lentils
! Yogurt
! Soy
! Edamame
! Greek
! Bean-based
Substitutes:
! Salmon
! Biscuits
Beans
Cheese
Many are soy based which will
! Oranges
! Dried
substitutes
Fish
! Cornbread
Beans
egg whites
Pasta ! Kefir
Yogurt
dogs
! Sandwich
Meat
Milk
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! Tofu
! Protein
bars/shakes
TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
FOOD PREFERENCES LIST—Check the foods you ENJOY or are WILLING to try.
Vegetables— Provide Fiber,
Vitamins, & Minerals
! Artichokes
! Asparagus
! Beets
! Broccoli
! Brussels
Sprouts
! Cabbage
! Carrots
! Cauliflower
! Celery
! Collard/Mustard
Greens
! Cucumbers
Fats— Provide Energy-Maintains Tissues
! Extra
! Avocado
/ Guacamole
! Coconut
Oil
! Butter
! Trans-Fat
Free Spread with Plant Sterols
! Trans-Fat
Free Spreads
! Butter
! Margarine
! Lard
! Fatback
Protein + Fat Foods
Beans
! Kale
! Lettuces
! Mushrooms
! Okra
! Onions
! Sprouts
! Tomatoes
! Zucchini
Nuts
Seeds
Nut Butters
! Walnuts
! Sunflower ! Peanut
! Almonds ! Chia
! Peanuts
! Almond
! Hemp
! Cashews ! Flax
! Pistachios
Favorite meals & snacks
! Peppers
! Spinach
with Olive Oil
! Olives
! Eggplant
! Green
Virgin Olive Oil
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
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TRANSCEND NUTRITION COUNSELING, LLC
10205 FOUR MILE CREEK ROAD, CHARLOTTE, NC 28277
E: [email protected]
P: (980) 339-8330
F: (877) 927-2987
THREE-DAY FOOD DIARY
Please record all food and beverages consumed for three days prior to your first
appointment. Do not forget to include:
1. Serving size
2. Method of preparation (fried, baked, grilled)
3. Sauces or condiments
Meal
(Breakfast,
Time
Lunch,
Dinner,
Snack)
Hunger
(0-5 with 5
being
Day 1
Day 2
Day 3
‘starving’)
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