Identification Referring Person / Agency

Carrie Schimmelpfennig, MS, Dietitian
Under the Umbrella, LLC
1136 W. 17th St. Suite B Bloomington, IN 47404
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: ___________________________
City: _________________________________________ State: ______ Zip: _________
Permanent home address: ______________________________________________
Apt.: _________________ City: ________________________________________
State: ________________Zip: ___________________
If in school, please indicate year and major:
Referring Person / Agency
Name: ___________________
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?
Family History: Has anyone in your family had any of the following problems?
(list family members)
Cancer _______________________
High Cholesterol _________________
Diabetes _______________________
Digestive Problems ______________
Eating Problems ______________
Thyroid Disease __________________
Heart Disease ___________________
Weight Problems_________________
High Blood Pressure______________
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
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”
“Bad Day”
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.