Leigh Wagner, MS, RD

Integrative Nutritionist
Email: lwagner@kumc.edu

One’s health and well-being are influenced by many different things, including lifestyle, family history,
emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of
your ability to give us an overall view of your general lifestyle and health habits.

New Patient Nutrition Assessment Form

First Name _______________________Middle Name_________________Last Name____________________

Address _______________________________ City ________________________State_____Zip:____________

Please indicate your preferred method of contact: home work cell email

Home Phone (_________)________-_________ Birth Date _____/_____/_____ Age __________

Work Phone (_________)________-_________ Email address: ___________________________

Cell Phone (_________)________-_________ Height: ___′ ____ ″ Weight: _______ Sex: _____

Blood Type (Please circle): A / AB / B / O / Unk

Occupation _____________________________ Marital Status ____________________________

Do you have children? Yes No Age of children____________________________

Are you pregnant? Yes No Due Date_________

With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)
Example: Sarah, age 7, sister
____________________________________________________________________________________________

____________________________________________________________________________________________

Primary Care Provider __________________________ Date of last physical exam ______________________

Other doctors or practitioners you see __________________________________________________________

Would you like to receive e-mail notifications regarding cooking classes/demonstrations? ______________

If yes, please sign ___________________________________________________________________________

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
GOALS AND READINESS ASSESSMENT
I would like to visit with the dietitian, today because…
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My food and nutrition-related goals are…

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My overall, health goals are…

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If I could change three things about my health and nutritional habits, they would be…

1. _____________________________________________________________________________________
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2. _____________________________________________________________________________________
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3. _____________________________________________________________________________________
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The biggest challenge(s) to reaching my nutrition goals is/are:

___________________________________________________________________________________________
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In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals…

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On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the
following:
To improve your health, how ready/willing are you to…
1 2 3 4 5
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (ex: work demands, sleep habits, physical activity)
Practice relaxation techniques
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

PAST MEDICAL AND SURGICAL HISTORY

Please indicate whether you or your relatives* have been diagnosed with any of the following diseases or
symptoms (specify which relative and the date of diagnosis). *Relatives include: parents, grandparents, siblings.
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
 Allergies (please specify type of allergy)
 Anemia
 Anxiety or Panic Attacks
 Arthritis (osteoarthritis or rheumatoid)
 Asthma
 Autoimmune condition (specify type)
 Bronchitis
 Cancer
 Chronic Fatigue Syndrome
 Crohn’s Disease or Ulcerative Colitis
 Depression
 Diabetes (Specify: Type I, II, Prediabetes,
Gestational Diabetes)
 Dry, itchy skin, rashes, dermatitis
 Eczema
 Emphysema
 Epilepsy, convulsions, or seizures
 Eye Disease (please specify)
 Fibromyalgia
 Food Allergies or Sensitivities
 Fungal Infection (athlete’s food,
ringworm, other)
 Gallbladder Disease/Gallstones
(specify)
 Gout
 Heart attack/Angina
 Heartburn
 Heart disease (specify)
 Hepatitis
 High blood fats (cholesterol,
triglycerides)
 High blood pressure (hypertension)
 Hypoglycemia (low blood sugar)
 Intestinal Disease (specify)
 Infammatory Bowel Disease (Crohn’s or
Ulcerative Colitis)
 Irritable bowel syndrome
 Kidney disease/failure or Kidney stones
 Lung disease (specify)
 Liver disease
 Mononucleosis
 Osteoporosis
 PMS
 Polycystic Ovarian Syndrome
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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
 Pneumonia
 Prostate Problems
 Psychiatric Conditions
 Seizures or epilepsy
 Sinusitis
 Sleep apnea
 Stroke
 Thyroid disease (hypo- or hyperthyroid)
 Urinary Tract Infection
 Other (describe)
Injuries Age Describe/Specify
 Back injury
 Broken (specify)
 Head injury
 Neck injury
 Other (describe)
Diagnostic Studies Age at study Describe/Specify
 Barium Enema
 Bone Scan
 CAT Scan: Abdom., Brain, Spine (specify)
 Chest X-ray
 Colonoscopy or Sigmoidoscopy (specify)
 EKG
 Liver scan
 NMR/MRI
 Upper GI Series
 Other (describe)
Operations Age at operation Describe/Specify
 Dental Surgery
 Gall Bladder
 Hernia
 Hysterectomy
 Tonsillectomy
 Other (describe)

Please complete the following information concerning your family’s health history:

If Living If Deceased If Living If Deceased

Age at Age at
Age Health Cause Age Health Cause
death death
Father Spouse/Partner
Mother Children
Siblings

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
MEDICAL SYMPTOMS QUESTIONNAIRE
Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having
recent or somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

Past 30 days Past 48 hours

Point Scale
0 – Never or almost never have the symptom
1 – Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
3 – Frequently have it, effect is not severe
4 – Frequently have it, effect is severe

HEAD
_______Headaches
_______Faintness
_______Dizziness
_______Insomnia
Total ______

EYES
_______ Watery or itchy eyes
_______ Swollen, reddened or sticky eyelids
_______ Bags or dark circles under eye
_______ Blurred or tunnel vision
(does not include near or far-sightedness)

Total _______
EARS _______ Itchy ears
_______ Earaches, ear infections
_______ Drainage from ear
_______ Ringing in ears, hearing loss Total _______

NOSE _______ Stuffy nose

_______ Sinus problems
_______ Hay fever
_______ Sneezing attacks
_______ Excessive mucus formation Total _______

MOUTH/THROAT
_______ Chronic cough
_______ Gagging, frequent need to clear throat
_______ Sore throat, hoarseness, loss of voice
_______ Swollen or discolored tongue, gums, lips
_______ Canker sores Total _______

SKIN _______ Acne

_______ Hives, rashes, dry skin
_______ Hair loss
_______ Flushing, hot flashes
_______ Excessive sweating Total _______

HEART _______ Irregular or skipped heartbeat

_______ Rapid or pounding heartbeat
_______ Chest pain Total _______

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

LUNGS _______ Chest congestion

_______ Asthma, bronchitis
_______ Shortness of breath
_______ Difficulty breathing Total _______

DIGESTIVE TRACT
_______ Nausea, vomiting
_______ Diarrhea
_______ Constipation
_______ Bloated feeling
_______ Belching, passing gas
_______ Heartburn
_______ Intestinal/stomach pain Total _______

JOINT/MUSCLE
_______ Pain or aches in joints
_______ Arthritis
_______ Stiffness or limitation of movement
_______ Pain or aches in muscles
_______ Feeling of weakness or tiredness Total _______

WEIGHT
_______ Binge eating/drinking
_______ Craving certain foods
_______ Excessive weight
_______ Compulsive eating
_______ Water retention
_______ Underweight Total _______

ENERGY/ACTIVITY
_______ Fatigue, sluggishness
_______ Apathy, lethargy
_______ Hyperactivity
_______ Restlessness Total _______

MIND _______ Poor memory

_______ Confusion, poor comprehension
_______ Poor concentration
_______ Poor physical coordination
_______ Difficulty in making decisions
_______ Stuttering or stammering
_______ Slurred speech
_______ Learning disabilities Total _______

EMOTIONS
_______ Mood swings
_______ Anxiety, fear, nervousness
_______ Anger, irritability, aggressiveness
_______ Depression Total _______

OTHER _______ Frequent illness

_______ Frequent or urgent urination
_______ Genital itch or discharge Total _______

GRAND TOTAL ________

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE: Please provide the names of

medications, supplements, and/or antibiotics that you are currently taking:

Medication/Supplement/ Dose Units Frequency Start Date Stop Date

Antibiotic
Example:
One-a-Day (brand) Men’s 1200 Mg Daily 08/12/2007 current
Multivitamin

Are you allergic to any medications? Yes No Please list: _______________________________

Please indicate how often you have taken antibiotics during each life stage:
< 5 times > 5 times
Infancy/ Childhood
Teen
Adulthood

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

LIFESTYLE

Physical Activity: Using the table, please describe your physical activity.

Activity Type/Intensity # Days Duration

(low-moderate-high) per week (minutes)
Stretching/Yoga
Cardio/Aerobics
(walking, jogging, biking, etc.)
Strength-training
(weight lifting, pilates, some yoga)
Sports or Leisure
Other (specify/describe)

Does anything limit you from being physically active?

___________________________________________________________________________________
Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):
Work_______ Family_______Social_______Financial_______Health_______ Other_______

What helps you to unwind?_______________________________________________________

On average, how many hours of sleep do you get? Weekdays_______ Weekends_______
Do you smoke? Never In the past Currently How long?__________
Alcohol use Never In the past Currently Type/amount/frequency______________________
Drug use Never In the past Currently Prefer not to discuss Type/frequency_________
WEIGHT HISTORY:
Would you like to be weighed today? Yes No
Height _______ Current Weight ______ Desired Body Weight ______
Highest Adult Weight ______ When? ______ Weight 1 year ago ______
Have you had any recent changes in your weight that you are concerned about? Yes No
If yes, please explain:__________________________________________________________________
DIGESTIVE HISTORY
 Do you associate any digestive symptoms with eating certain foods? Yes No
 Please explain:_________________________________________________________________
______ _______________________________________________________________________
 How often do you have a bowel movement? __________
 If you take laxatives, what type/brand and how often?
______________________________________________________________________________

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
 Would you describe your stools are hard, soft, or loose? (circle one)
 Please indicate how often you experience the following symptoms:
Heartburn Often Sometimes Rarely
Gas Often Sometimes Rarely
Bloating Often Sometimes Rarely
Stomach Pain Often Sometimes Rarely
Nausea/Vomiting Often Sometimes Rarely
Diarrhea Often Sometimes Rarely
Constipation Often Sometimes Rarely

DIET HISTORY
Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural,
religious or other)?
Please list any food allergies, sensitivities or intolerances ___________________________________
_____________________________________________________________________________________
Who prepares the majority of your meals? ___________ Who shops for food? ___________________
Where do you shop for food? ____________________________________________________________
What percent of the foods you eat are… whole _______% organic_______% convenience ________%
If you do, how much time do you spend cooking/preparing meals each day? ___________________
Please indicate the materials you use for cooking and food storage:

-iron -stick
Do you find cooking difficult? describe __________________________
INTAKE INFORMATION:
If you follow a special diet/nutritional program, check the following that apply:

Loss
___________________
Which meals do you eat regularly, check all that apply:
Supper _)
The nutrition/eating habits that are most challenging for me: ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The nutrition/eating habits that I am most pleased with: ____________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Beverage Intake: Please indicate the beverages you drink, and how often you drink them. Fill in the
“Daily Amount”, “Weekly Amount”, and/or “Monthly Amount”

Beverage Type Daily Amount Weekly Monthly Amount

Amount
Example:
2 – 8 oz cups __ __
Coffee: X reg decaf latte
Water:

Tea: what type(s)?________________

Milk alternative Type_____________

Other _________________________

Food Intake: Please indicate the frequency that you eat the following:
2-3 1 2-3 1 2-3
How often do you eat: Never
times/mo. time/week times/week times/day time/day
Fast food
Restaurant food
Vending machine food
Cafeteria or buffet food
Frozen meals
Home-cooked meals
Leftovers
Beef (hamburger, steak, etc.)
Pork (chop, loin, ham, bacon, etc.)
Liver
Lamb
Poultry (chicken, turkey, etc.)
Deli meat, type:
Fish, type:
Soyfoods, type:
Beans, type:
Crackers, type:
Cookies, cakes, muffins
Whole grains, type:
Fresh/Raw vegetables
Cooked vegetables
Fruit, fresh or frozen
Canned Vegetables or Fruit
Margarine
Dairy (Milk, yogurt, cheese, butter)
French fries
Fried meat (chicken, fish)
Foods with added
sweeteners/sugar, type:
Artificial sweeteners, type:
Meal Replacements, type:

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

Food cravings
_________________________________________________________________________________

Food dislikes
__________________________________________________________________________________

Eating Style: Based on how you eat on a regular basis, please check all that apply:

-eater

Travel frequently

The food/nutrition questions that I would like to ask are:____________________________________

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Revised August 2011