Alison

Name *

Name

First Name

Last Name

Your top 3 health concerns

What do you want to talk about during our session?

Have you ever been on a special diet for any reason? Explain

Medical History

Include any recent or past diagnoses for yourself, any lab values that have been outside the range of normal etc.

Any complications of pregnancy, birth or postpartum?

Are you currently taking any medications or supplements?

Please name each along with dose

Are you currently being treated by a physician or another healthcare provider? Explain

How many hours of sleep do you get on a usual night?

What does your typical diet look like in a day?

List your breakfast, lunch, dinner, snacks and anything else you'd normally eat or drink in a day.

How often do you cook?

How much water do you drink in an average day?

How many alcoholic drinks do you have in a typical week?

(1 drink = 4 ounces of wine, 1.5 ounces of liquor, 12 ounces of beer)

What do you hope to get from this session with a nutritionist?

Cleo Intake Form