Nutrition and diet for cancer and chronic diseases

Register

Name

First

Last

Address

City/State/Zip

Phone

Gender

Male Female

Birth Date

Medical History

Diagnosis

Surgery

Yes

Physicians Name(s):

Would you like to have information shared with your medical team?
Yes
No
If yes, you will need to complete a release at your first visit and provide the address of your physician(s)

Other Nutrition / Health Concerns

What would you like to learn during our session(s)? What are your goals for nutrition therapy?

Do you take any vitamins or herbal supplements?
Yes
No
Please list the supplements and doses:

Do you take any prescribed medications?
Yes
No

Do you remember to take them?
Yes
No

Any side effects?
Yes
No

Please list the medications and doses to help identify any possible food/drug interactions:

Have you read any books about nutrition and your condition?
Yes
No

If yes, which one(s) and how have they changed your diet?

Eating History

Have you ever changed your diet?
Yes
No

Why did you change?

What did you change?

Did you find the the change helpful?
Yes
No

Food Preferences

What foods do you like?

Please list any food you no longer eat and why (example: meat, vegetarian)

Do you crave any foods?

Are you experiencing problems with nausea, vomiting, taste changes, or lack of appetite?
If yes, has it limited your ability to eat normal volumes of food and maintain your weight?

Are there any particular foods you have problems tolerating?
(Foods that make you feel bad or cause abdominal pain, diarrhea, constipation, ...)
Yes
No

Are you allergic to any foods?
Yes
No

Weight History

	Weight	Age / Year
Highest weight as an adult
Lowest weight over the past year
Weight one month ago
Weight 6 months ago

How tall are you?

Alcohol:
How many servings of alcohol
do you have per week?

Smoking:
Have you ever smoked?
Yes
No

Sleeping:
How many hours of sleep
do you get per night?

Do you wake rested?
Yes
No

Exercise

If you are exercising, please list how much time, if any, you spend in each type in a typical week.

Light general exercise (cleaning, gardening):
Light cardiovascular exercise (walking):
Intense cardiovascular (Stairclimber, elliptical traininer, running):
Sports, Dance Class, etc.
Strength training (weights):
Flexibility (stretching, yoga, Tai Chi):
Other:

Rate on a scale of 0 - 10 with 0 being low and 10 being high:

Stress Level

Energy Level

What do you do to reduce stress?

Relaxation

What hobbies / activities do you enjoy on a regular basis?

How many hours a week do you spend on these activities?

Social Factors

How do your friends/family influence your eating patterns?

Who do you find supportive?

Family History

Any family history of
heart disease?	Yes No
overweight?	Yes No
cancer?	Yes No
high blood pressure?	Yes No
osteoporosis?	Yes No

Eating Patterns

How many meals do you eat out per week?

Do you routinely skip meals?
Yes
No

Is there a particular meal you have trouble with?
Yes
No

Problem:

Typical Daily Pattern:

In trying to make small dietary changes in your current lifestyle it is important to know what a typical day looks like to you. Here is an example of the information that will be helpful.

7:00	Wake, walk the dog 20 minutes
7:30	Breakfast at home: coffee, 2 T cream, 1 Lenders Bagel, 1 T light cream cheese
8:00	Leave for work
10:00	Snack: Donut, 16 ounce Diet Coke
12:00	Lunch at Subway: 16 oz Coke, 6 inch Sub with Turkey, mayonnaise and tomato, small bag chips...

Use this space to record your daily pattern:

Please include any other information that would be helpful for me to know:

Please click on the "Submit" button to send your answers