Initial Assessment Form

Please fill out this form prior to your first appointment.

 

Please complete the form below

Name *
Name
Phone
Phone
Which statements best describe you?
Please list your medications.
Please list your supplements.
Please note: 1 drink = 341 mL (12 oz) 5% alcohol beer 1 drink = 145 mL (5 oz) 12% alcohol wine 1 drink = 85 mL (3 oz) 18% alcohol port wine 1 drink = 45 mL (1.5 oz) 45 % spirits or liquor
If yes, how many cups of coffee do you drink per day?
If yes, how many sodas do you drink per day?
If yes, which statement best describes you?
Please note: 1 serving = 250 mL (1 cup) milk 175 g (¾ cup) yogurt or kefir 50 g (1 ½ oz.) cheese (size of two thumbs) 1/3 cup (50 g) shredded cheese 250 mL (1 cup) cottage cheese
Please note: 1 serving = 125 mL (½ cup) fresh, frozen or canned vegetables
Please note: 1 serving = 125 mL (½ cup) fresh, frozen or canned fruit
What fat do you use in cooking?