Carrie Schimmelpfennig, MS, Dietitian Under the Umbrella, LLC 1136 W. 17th St. Suite B Bloomington, IN 47404 Identification Name__________________________________________ Occupation_______________________________ Date of birth: ________________ Age: ________ Gender: M ______ F ______ Phone #s where I may call you: ________________________________________ May I leave a message? Yes ____ No ____ E-mail address where I may contact you: _______________________________________________________ Local street address: ___________________________ Apt.:__________ City: _________________________________________ State: ______ Zip: _________ Permanent home address: ______________________________________________ Apt.: _________________ City: ________________________________________ State: ________________Zip: ___________________ If in school, please indicate year and major: _____________________________________________ Referring Person / Agency Name: ___________________ Phone:__________________ Address ___________________________________________________________ May I contact the referring provider to thank them for the referral and confirm your first scheduled appointment? (circle) Yes or No Medical History: Please check if you have had any of the following medical problems Alcohol _____ Digestive Problems _____ Allergies, if yes please specify Diarrhea/Constipation _____ _______________________ Drug Abuse _____ Anemia _____ Heart Disease _____ Anorexia _____ High Blood Pressure _____ Binge or compulsive eating _____ High Cholesterol _____ Bulimia _____ Kidney or Liver Disease _____ Cancer _____ Low Bone Density _____ Cigarette Smoking _____ PCOS _____ Depression / Anxiety ____ Self Injury _____ Diabetes _____ Thyroid Disease _____ Other: ______________________________________________________________________ Have you ever had a period? If yes when was your last menstrual cycle? ____________________________________________________________________________ Medications prescribed by doctor, including birth control? ___________________________________________________________________________ Over the counter medications, e.g. diet pills, water pills, laxatives? ___________________________________________________________________________ Supplements? ___________________________________________________________________________ Family History: Has anyone in your family had any of the following problems? (list family members) Cancer _______________________ High Cholesterol _________________ Diabetes _______________________ Osteoporosis_____________________ Digestive Problems ______________ Stroke__________________________ Eating Problems ______________ Thyroid Disease __________________ Heart Disease ___________________ Weight Problems_________________ High Blood Pressure______________ Other___________________________ Sleep History Average hours of sleep ________ # of times/week ________ Low hours of sleep ________ # of times/week ____________ High hours of sleep ________ # of times/week ____________ Alcohol Intake Average # of drinks on occasions _____ Average # nights per week you drink _____ High # of drinks on occasions ______ Exercise History Are you a member of a sports team, club sport, or fitness center? (Circle) Yes or No If yes please list._____________________ Describe current exercise regimen Type of activity / Number of times a week / Number of minutes per session ___________________________________________________________________________ ___________________________________________________________________________ Weight History: How do you perceive your weight now? (X on line) Extremely Thin __ Somewhat Thin__ Normal Weight__ Somewhat Overweight __ Extremely Overweight__ How satisfied are you with your current weight? (X on line) Extremely ____ Satisfied ____ Neutral ____ Dissatisfied ___Extremely Dissatisfied ___ Height _______ Do you weigh yourself, If yes how many times a day? _________ If so, what is your current weight? ______ What is your approximate goal weight? _____ Highest body weight (non-pregnant)_____ Lowest adult body weight ________ What years(s) or age(s) _____ What years(s) or age(s) _____ Have you lost or gained weight recently? (Circle) Yes or No If so how much and time frame of weight loss/gain? ____________________________ Please indicate the methods you have most frequently used to control your weight in the past: Counting Calories ____ Fasting ____ Laxative use ____ Specific diets ____ Diet pills _____ Over-exercise _____ Purging _____ Restricting intake _____ Chewing/Spitting _____ Other (specify) ______________________ Eating Patterns How many meals a day do you eat? _____ Do you skip meals? _____ If yes, which ones do you skip and why? ____________________________________ What types of beverages do you drink and how often do you consume them? _______________________________________________________________________ Do you engage in other activities while eating (reading, driving, etc.)? Yes or No Do you eat at the table? Yes or No Do you feel as if you eat fast? Yes or No Who does the grocery shopping? _______________________ Who prepares the food at home? _______________________ Do you feel as if you have a strong support system from family or friends?_____________________________________________________________ Do you receive any financial assistance (i.e. food stamps)? _______________________ Do you read food/nutrition labels? If so what do you look for? ____________________________________________________________________________ Please indicate a typical intake on a “good day” vs. a “bad day”, if they differ “Good Day” Breakfast________________________________________________________________ Lunch____________________________________________________________________ Dinner___________________________________________________________________ Snacks___________________________________________________________________ “Bad Day” Breakfast_________________________________________________________________ Lunch____________________________________________________________________ Dinner___________________________________________________________________ Snacks___________________________________________________________________ What are your “safe foods”?_________________________________________________ What are your “fear” foods? _________________________________________________ Are there any foods you would consider “binge” foods? ___________________ What do you hope to accomplish through our visit? ____________________________________________________________________________ What are your short-term goals? ____________________________________________________________________________ What are your long-term goals? ____________________________________________________________________________ Please feel free to share any additional information here.
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