Best number to reach you for phone appointments
Date of Birth
Occupation - If applicable, what is your work schedule and hours worked per week? (i.e., do you work standard 8am-5pm hours Monday through Friday or do you have shift work, travel, etc.)
Marital Status - If you have children, how many and what ages?
Height, Weight, Body composition (if known, body fat%)
Briefly describe your weight history
Describe your sleep patterns (time of day you go to sleep and time you wake up). Do you feel rested when you wake?
What are your top health and nutrition-related goals and why now?
What do you see as your main nutrition-related challenges and concerns related to your everyday nutrition?
Are you currently following a particular dietary pattern such as vegan/vegetarian, Paleo, gluten-free, etc.?
Please list any foods you dislike or will not eat (along with reasons):
Have you ever been clinically diagnosed with an eating disorder or disordered eating? Please explain.
If you have not been diagnosed with an eating disorder, but you have experienced purging, bingeing, or restricted eating behaviors, please comment here for our discussion.
How often do you dine out and what are some examples of places where you dine out?
Any other lifestyle details to share?
FOR ATHLETES: What are your main training and race nutrition challenges and concerns? Do you have a coach? (if yes, please provide name) What are your main races, events, or other athletic pursuits scheduled in the next year?
Please explain and also indicate whether there is any family history of the above:
Have you ever had any surgeries? Explain:
Have you ever had any broken bones? Explain:
Have you had any head injuries or concussions? Explain:
List any allergies to foods, animals, plants, and medications:
List in detail all medications you take (brand, dosage, time of day):
List in detail all herbal or other nutritional supplements you take (brand, dosage, time of day):
How often do you have a bowel movement and please describe consistency (e.g., loose, solid and formed, floaty, etc.):
Are you using any hormone replacement therapy (topical, oral)? Please explain:
FOR FEMALES: Are you pregnant? Are you using any form of oral contraceptive or intrauterine device? Please explain: If you have menstrual periods, what is the duration of your average menstrual cycle and how heavy is the flow?
Is there any additional information you would like to share with Dina to help your work together?
How did you hear about Dina?
You will be responsible to pay a $50 late cancel fee for any missed or cancelled appointments, not changed at least 24 hours in advance of the scheduled appointment time (via the online Nutrition Mechanic scheduler or by e-mailing Dina at email@example.com). If for some unexpected reason Dina has to cancel or reschedule an appointment with you within the 24-hour window, you will receive an extra 30-minute consultation at no charge. Please provide an electronic signature below, stating that you agree to these terms:
Thank you, I look forward to working together!