Gender: Date of Birth/Age:
What is your occupation?
What is your work schedule like? (days/week and hours/day)
Who do you live with?
What is your primary purpose for meeting with me?
Why is this important to you?
What do you hope to accomplish through our visits?
What support systems do you have? Why/How are these people support?
Please list/describe any current or past medical diagnoses or procedures:
Please list/describe any mental health concerns I should be aware of:
Are you currently working with a therapist?
List any significant family medical/health history:
Do you take any vitamin/mineral or herbal supplements? If yes, please list names and dosage.
List any medications you are taking (prescription and/or over the counter):
When was your last physician visit?
Are you currently getting your period?
Have there been any inconsistencies with your menstrual cycle? If yes, please describe.
Have you ever received a gastrointestinal (GI) diagnoses? If yes, please describe
Do you have any known food allergies, sensitivities or intolerances?
How often do you have a bowel movement?
Please describe any digestive discomfort you experience regularly and please indicate how often.i.e. constipation, diarrhea, gas, bloating, feeling full quickly, etc.
Food and Eating History
What was food like in your house growing up?
Does anyone in your family have a history of dieting, disordered eating, or eating disorders?
Tell me about your dieting and/or disordered eating history.
Have you ever worked with a dietitian/nutritionist? If yes, tell me about your experience.
What is food like in your house now?
How many meals a day do you eat?
Do you skip meals? If yes, which ones and why?
What factors affect what and when you eat? How/why do they affect this?
Do you ever eat for reasons outside physical hunger, such as anxiety, stress, boredom, sadness, loneliness, etc?
Where do you eat your meals?
Do you eat and multi-task?
Do you eat differently when you’re alone vs with others?
Do you feel you eat particularly fast or slow?
Do you cook? Do you like to cook? Do you know how to cook?
Who does the grocery shopping and cooking in your household?
Does your diet have a lot of variety or does it tend to be the same from day to day?
What foods do you love? What foods do you dislike?
Are there any foods that feel like binge/trigger foods for you?
Are there any foods that feel “safe” to you?
Please list the usual time and typical daily intake for each meal.
What do you usually drink throughout the day?
Do you consume alcohol? If yes, please specify type, amount and frequency.
How much sleep do you get? What’s the quality of your sleep?
Please rate your daily stress from 1 (low) to 10 (high):
How do you manage stress?
Do you smoke?
What types of social media do you use?
How do you feel social media affects you?
Have you ever had a consistent exercise routine?
Tell me about your pastexercise habits/relationship to exercise:
Tell me about your currentexercise habits/relationship to exercise:
Are you currently exercising on a regular basis? If yes, describe:
You can leave blank if you prefer or if it feels uncomfortable, we can discuss it in session together.
Height: Current weight (leave blank if unsure):
Ave weight. for the past 2 to 3 years?
Weight you feel most comfortable: When were you last at that weight?
Highest adult weight? Age:
Lowest adult weight? Age:
Pre-pregnancy weight? How much weight did you gain with pregnancy?
Have you lost or gained weight recently?
How much? Time frame?
Do you weigh yourself currently? If yes, how frequently?
Please circle how you currently feel about your body.
strongly dislike dislike slightly satisfied satisfied very satisfied