NUTRITION HEALTH HISTORY
TODAY'S DATE
MM/DD/YYYY
NAME
ADDRESS 1
ADDRESS 2
CITY, ZIP
HOME TELEPHONE
BEST TIME TO CALL
AM
PM
OTHER TELEPHONE
EMAIL
DATE OF BIRTH
MM/DD/YYYY
AGE
YRS OLD
HEIGHT
INCHES
WEIGHT
POUNDS
FOOD ALLERGIES
SEASONAL ALLERGIES
NO
YES
PET ALLERGIES
NO
YES
USE TOBACCO
NO
YES
HOW MUCH?
PGK/DAY
ALCOHOL
NO
YES
CAFFEINE USE
NO
YES
WHAT WOULD YOU WISH TO ACHIEVE FROM THE PRACTICAL HEALTH EDUCATION SESSION:
WISH LIST
PRESENT ILLNESSES: DIABETES, HYPERTENSION, HEART DISEASE, HIGH CHOLESTEROL, OSTEOPOROSIS ETC
PAST ATTEMPTS AT WEIGHT ELIMINATION, (DIETS, MEDICATIONS, SPECIAL PROGRAMS)
DIETS, MEDS, PLANS, SPEC PROGRAMS:
WEEKLY EXERCISE
PLAN?
EXERCISE PLAN
WEEKLY FUN PLAN-STRESS RELIEF:
STRESS RELIEF-->