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On Your Mark Nutrition
Precision Dietetics & Nutrition
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Katie Mark
Dr. Lorenzo Gonzalez
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Functional Nutrition for Fitness, Health & Wellness
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About
On Your Mark Nutrition
Precision Dietetics & Nutrition
Concierge Nutrition
Sport Performance
Functional Nutrition
Investigative Nutrition
Testimonials
Frequently Asked Questions
Policies
Team
Katie Mark
Dr. Lorenzo Gonzalez
Concierge Services
Sport Performance Nutrition
Functional Nutrition for Fitness, Health & Wellness
Investigative Nutrition
Testing
Education
Blog
Guest Articles
Guest Blogs
Tufts Nutrition
Contact
Client Login
Medical Health History & Nutritional Questionnaire
Medical Health History
&
Nutritional Questionnaire
Name
*
First Name
Last Name
Birthday
*
MM
DD
YYYY
Age
*
What is your occupation?
*
Referred By:
Why do you want to see a Dietitian? (check all that apply)
*
Weight Loss
Weight Gain
Training Goals
Vegetarian/Vegan Diet
Gluten-Free Diet
General Healthful Eating
Sport Performance
Fitness Goals
Other
Have you seen a Dietitian (licensed nutrition professional) or Nutritionist (non-licensed nutrition professional) before?
*
Yes
No
What are your top 3 short-term and/or long-term goals?
*
HISTORY
Height
*
Do you know your body fat percentage?
*
Yes
No
If Yes, what is your body fat %?
How was your body composition measured? (e.g., BIA, DEXA, Ultrasound, Skin Calipers, etc.)
*
Current weight?
*
Usual weight?
*
Goal weight?
*
How long ago were you at this usual weight?
How often do you weigh yourself?
*
Daily
Weekly
Once per month
Rarely
Never
Have you ever had concerns about your weight?
*
Yes
No
If Yes, please explain:
Are you being treated for any medical condition?
*
Yes
No
If Yes, please explain:
Are you or have you been anemic?
*
Yes
No
If Yes, please explain:
Do you have diabetes or high fasting blood sugar?
*
Yes
No
If Yes, please explain:
Do you have asthma or exercise-induced asthma?
*
Yes
No
If Yes, please explain:
Are you undergoing treatment for high blood pressure?
*
Yes
No
If Yes, please explain:
Do you have or have you ever had kidney disease?
*
Yes
No
If Yes, please explain:
Do you have or have you ever had frequent headaches?
*
Yes
No
If Yes, please explain:
Have you ever had a concussion or head injury?
*
Yes
No
If Yes, please explain:
Have you ever had a broken bone or fracture?
*
Yes
No
If Yes, please explain:
Have you ever had a shoulder injury?
*
Yes
No
If Yes, please explain:
Have you ever had a hip or knee injury?
*
Yes
No
If Yes, please explain:
List any surgeries you have had:
When did you last complete blood work?
*
INTAKE
List any medications you are taking:
*
List any dietary supplement(s) you are taking. Please include supplement brand and dosage:
List foods you dislike or will not eat:
*
Do you like to cook?
*
Yes
No
Do you follow any particular diet for personal or religious reasons?
*
Yes
No
If Yes, please specify:
Who prescribed this diet for you?
Doctor
Friend/Family
Self
Other
Do you have any food ALLERGIES?
*
Yes
No
Unsure
If Yes, please list which foods you are ALLERGIC to:
Do you have any food SENSITIVITIES?
*
Yes
No
Unsure
If Yes, please list which foods you are SENSITIVE to:
Do you drink alcohol?
*
Yes
No
If Yes, number of drinks: _____ per day _____ number of days per week
1 drink = 1.5 oz 80-proof liquor; 5 oz wine; 12 oz beer
Do you consume caffeinated beverages/products?
*
Yes
No
How would you describe your recent eating/behavior patterns (last 3 months)? (check all that apply)
*
Eat 3 meals per day
Snack between most meals
Exercise excessively
Graze most of the day
Overeat most of the day
Skip/miss meals
Binge or uncontrollable eating
Induce vomiting
Restrict amount of food consumed
Restrict types of food consumed
Use laxatives or diuretics
Other
LIFESTYLE
Please indicate if you:
*
Smoke (e.g., cigarettes, marijuana)
Vape
Consume Edibles
None
If Yes, for how many years?
How many hours of sleep do you get per WEEKDAY night?
*
How many hours of sleep do you get per WEEKEND night?
*
Please describe your sleep patterns:
*
FOR PERFORMANCE ATHLETES
What is your current training cycle?
*
(e.g., off season, pre-season, in-season, taper week(s), etc.)
Please briefly describe your weekly training.
*
(e.g., Monday-Sunday; duration; intensity; training goal for the day, etc.)
COMMITTMENT
What is your definition of success?
*
Are you willing to make some sacrifices toward reaching your goal(s)?
*
Yes
No
Somewhat
Not Sure
What are your "bad" habits that stop you from reaching your goals?
*
In relation to working toward your goal(s), what are your problem areas (e.g., behavior, habits, etc.)?
*
On a scale from 1 to 5, how committed are you toward your goal(s)?
*
0 = not committed at all; 1 = 25% committed 2 = 50% committed 3 = 75% committed 4 = 90% committed 5 = 100% committed
0
1
2
3
4
5
OTHER
Are there any other tests you are interested in adding on?
*
Please select from below any tests you are interested in completing that you are not already completing in your package. Please feel free to email Katie for more information about each of the tests.
DUTCH Test: a saliva and urine test that provides a comprehensive view of your sex hormones.
Dietary Antigen Test: a blood test that investigates 4 different ways your body's immune system reacts to food, including IgE (food allergen), IgG4 (delayed food sensitivity), IgG (mediates the immune response) and C3d (a potent immunity activator that amplifies the IgG4 response).
Advanced Intestinal Barrier Assessment: a blood test that analyzes the strength of the gut barrier and histamine intolerance.
GI-Map: a comprehensive stool test that evaluates the DNA of the organisms living within the gut using the most advanced qPCR technology.
Blood Work: a comprehensive blood test looking at your nutritional status, metabolic health, cardiovascular health and more. Specific blood biomarkers are individualized to your needs.
None
What methods of communication do you prefer while working with Katie?
*
Select all that apply.
Text
Call
Email
Are you interested in learning more about nutrition during this program or not at all?
*
Yes
Minimal
No
FEMALES ONLY
If you are on birth control or taking any hormone replace therapy, please list which type and for how long you've been taking it.
Are you pregnant?
Yes
No
If you are pre-menopausal or peri-menopausal, how often do you have periods and for what duration?
FOR ALL INDIVIDUALS
Please provide any additional information you feel may be helpful.
The above answers have been answered correctly and truthfully to the best of my knowledge.
*
Yes
Thank you!
