On Your Mark Nutrition

Medical Health History & Nutritional Questionnaire

Medical Health History

&

Nutritional Questionnaire

Name *
Name
Birthday *
Birthday
Why do you want to see a Dietitian? (check all that apply) *
HISTORY
INTAKE
1 drink = 1.5 oz 80-proof liquor; 5 oz wine; 12 oz beer
How would you describe your recent eating/behavior patterns (last 3 months)? (check all that apply) *
LIFESTYLE
Please indicate if you: *
FOR PERFORMANCE ATHLETES
(e.g., off season, pre-season, in-season, taper week(s), etc.)
(e.g., Monday-Sunday; duration; intensity; training goal for the day, etc.)
COMMITTMENT
0 = not committed at all; 1 = 25% committed 2 = 50% committed 3 = 75% committed 4 = 90% committed 5 = 100% committed
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.
What methods of communication do you prefer while working with Katie? *
Select all that apply.
Are you interested in learning more about nutrition during this program or not at all? *
FEMALES ONLY
FOR ALL INDIVIDUALS
The above answers have been answered correctly and truthfully to the best of my knowledge. *