Patient Information
- Full Name: _________________ Date: _________________
- Date of Birth: _____________ Age: _____ Gender: _______
- Address: ________________________________________________
- Phone: (Home) _____________ (Mobile) _________________
- Email: ________________________________________________
- Emergency Contact: _____________ Phone: ________________
Health Insurance Information
- Primary Insurance: ______________________________________
- Policy Number: ________________________________________
- Secondary Insurance (if applicable): _______________________
Medical History
Current Health Concerns
- Primary reason for visit: _________________________________
- Current medications and supplements: _____________________
- Known allergies: _______________________________________
Medical Conditions (check all that apply)
□ Diabetes
□ Hypertension
□ Heart Disease
□ Thyroid Disorder
□ Gastrointestinal Issues
□ Other: _______________
Dietary Assessment
- Current diet type: _____________________________________
- Food allergies/intolerances: ____________________________
- Recent weight changes: ________________________________
- Weight goals: ________________________________________
Lifestyle Factors
- Physical activity level: _________________________________
- Occupation: _________________________________________
- Sleep patterns: _______________________________________
- Stress level (1-10): ___________________________________
Authorization
I certify that the above information is correct to the best of my knowledge.
Signature: _________________ Date: _________________
Office Use Only
Provider: _________________ Chart #: _________________