Comprehensive Nutrition Medical History Form

Patient Information

• Full Name: _________________________ Date: //___
• Date of Birth: //___ Age: _____ Gender: _____
• Phone: _____________ Email: _________________________

Medical History

Current Health Conditions (check all that apply)

□ Diabetes □ Hypertension □ Heart Disease □ Thyroid Disorders □ Gastrointestinal Issues □ Food Allergies □ Other: _________

Medications and Supplements

Current Medications: _________________________________ Supplements/Vitamins: ________________________________

Anthropometric Data

• Height: _____ Weight: _____ BMI: _____
• Usual Weight: _____ Goal Weight: _____
• Recent Weight Changes: □ Loss □ Gain Amount: _____ Time Period: _____

Dietary Assessment

Eating Patterns

• Meals per day: □ 1-2 □ 3-4 □ 5+
• Snacks per day: □ 0 □ 1-2 □ 3+
• Who prepares meals? □ Self □ Family □ Restaurant □ Other

Food Allergies/Intolerances

List all: ________________________________________

Dietary Restrictions

□ Vegetarian □ Vegan □ Gluten-Free □ Dairy-Free □ Other: ________________________________________

Lifestyle Factors

Physical Activity

• Type: ________________________________________
• Frequency: _____ times per week
• Duration: _____ minutes per session

Sleep Patterns

• Average hours per night: _____
• Sleep quality: □ Poor □ Fair □ Good □ Excellent

Goals and Concerns

Primary nutrition goals: _____________________________ Main health concerns: ______________________________

Authorization

Signature: _________________________ Date: //___