Dragonfly Hot Yoga Madison WI

Yoga, Barre & Fitness Studio

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Nutrition History

Name*
First Last
Email*
Birthday*
MM slash DD slash YYYY
Height*
Current Weight*
Desired Weight*
Check Any Conditions Family Members (extended blood relatives) Have or Have Had*
- None of these
- Heart Disease
- Osteoporosis/arthritis
- Diabetes
- High Cholesterol
- Cancer
- Thyroid Condition
- Anemia
- Malnutrition
- IBS/Crohns/GI Problems
- Celiac Disease
- Obesity
- Chronic Fatigue Syndrome
- High Blood Pressure
- Liver Disease
- PCOS
- Pulmonary Diseases
- Kidney Disease
- Other
Please describe
Check Any Conditions You Have or Have Had*
- None of these
- Heart Disease
- Osteoporosis/arthritis
- Diabetes
- High Cholesterol
- Cancer
- Thyroid Condition
- Anemia
- Malnutrition
- IBS/Crohns/GI Problems
- Celiac Disease
- Obesity
- Chronic Fatigue Syndrome
- High Blood Pressure
- Liver Disease
- PCOS
- Pulmonary Diseases
- Kidney Disease
- Other
Please describe
Do you currently follow any specific diet pattern (ie.vegetarian, vegan, DASH)? If so, please list:*
How long have you been at your current weight? *
If your weight has changed, please describe how you gained or lost weight, and the time frame that it occurred:*
What are your goals? Why are you seeing a Registered Dietitian?*
Do you cook for yourself? If so, how often and what type of food do you prepare?*
Do you grocery shop?*
- Yes
- No
- Other
Please explain
How would you describe your eating habits? *
- Good
- Fair
- Poor
Do you want to change your eating habits?*
Please list any vitamin/herb/dietary supplement (ie. Multivitamin, craetine, fish oil, etc.) that you take. List the type of supplement, amount, and brand:*
Please list any prescribed and over-the-counter medications you are currently taking. List the type, amount, and dosage:*
Do you have any food allergies or intolerants? If so, please list:*
How often do you eat out per week? Please provide numbers for each:*
Breakfast: Lunch: Dinner:
Select a number to indicate how ready you are to make dietary changes. 1= not ready and 12= very ready:*