Cart 0

Programs Articles Dietitians FAQ Contact

Cart 0

Programs Articles Dietitians FAQ Contact

Forms

Client History Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Email *

Today's Date *

YYYY

Date of last medical checkup *

YYYY

Birthdate *

YYYY

Age *

Sex *

Height *

Feet

Height *

Inches

Weight *

Explain your personal goals in working with a Nutriworks, Inc. Dietitian: *

Health History *

Have you ever been told that you have (check all that apply):

None

Diabetes

Heart Disease

Lung Disease

Liver Disease

GI Disorders

High Blood Pressure

Hardening of Arteries

Ulcers

Cancer

Arthritis

High Cholesterol

Other

If other, explain:

Do you have complaints of the following? *

Lack of appetite

Difficulty chewing/swallowing

Constipation

Indigestion

Asthma

Nausea

Vomiting

None

Other Complaint

If other, explain:

Do you smoke? *

If yes, for how long?

For Females Only:

Are you pregnant?

How many months?

Is menstruation normal?

If no, please explain:

List your current medication(s) and reason(s) for taking them: OR type N/A *

List your current supplement(s) and reason(s) for taking them OR type N/A *

Occupation: *

Do you grocery shop or does someone else grocery shop for you? *

What store(s) do you or someone in your household primarily buy food from? *

How often do you dine out? (fast food and restaurant food) *

Are you currently participating in a cardiovascular exercise program? *

Are you currently participating in a resistance/strength exercise program? *

How often do you exercise? *

Do you have a trainer/coach? *

If yes, please provide name:

Please also provide their phone number/email address:

Do you belong to a gym or club? *

If yes, which gym or club?

Please also provide the gym or club location:

If you answered no to the above questions, when was the last time you participated in an exercise/training program?

Thank you!

The purpose of this form is to securely collect your personal information, including your health & fitness history.

This form submits encrypted information over a secure connection to ensure the safety of your personal health information.

Favorite Foods

Name *

First Name

Last Name

Vegetables *

Asparagus

Cauliflower

Iceberg Lettuce

Romaine Lettuce

Other Lettuce/Greens

Onions

Tomato

Broccoli

Celery

Marinara Sauce

Brussels Sprouts

Cucumber

Mixed Vegetables

Spaghetti Sauce

Carrots

Green Beans

Mushrooms

Bell Peppers

Beets

Spaghetti Squash

Zucchini

Yellow Squash

Butternut Squash

Acorn Squash

Swiss Chard

Turnips

Spinach

Rutabaga

Jicama

Fruits *

Apple

Blueberries

Dried Apricots

Grapes

Nectarine

Pineapple

Cantaloupe

Figs

Dates

Honeydew

Orange

Plum

Applesauce

Fruit Cocktail

Raisins

Banana

Mango

Peach

Strawberries

Raspberries

Blackberries

Juice

Starches *

Oatmeal

Cereal

Granola

Muesli

Whole grain bread

Gluten free bread

Sourdough bread

White bread

Rolls

Rye Bread

Corn Tortillas

Flour Tortillas

Whole Wheat Tortillas

English muffin

Pita

Bagel

White Rice

Brown Rice

Wild Rice

Millet

Couscous

Quinoa

Farro

Potatoes

Sweet potatoes

Peas

Corn

Popcorn

Eggplant

Pasta

Pancakes

Crackers of any sort

Pretzels

Waffles

Dairy *

Skim milk

2% milk

Whole milk

Almond milk

Coconut milk

Soy milk

Other milk product

Regular yogurt (plain)

Lowfat yogurt

Greek yogurt (plain)

Greek yogurt (fruited)

Soy yogurt

Coconut yogurt

Fat Free cheese

Lowfat cheese

Regular cheese

Cottage cheese

Proteins *

Eggs

Egg Whites

Protein Powder

Tempeh

Soy meat

Tofu

Turkey

Chicken

Beef

Pork

Bacon

Sausage

Shrimp

Fish

Crab

Scallops

Mussels

Clams

Beans (black, kidney, etc.)

Lamb

Quail

Bison

Venison

Fats *

Avocado

Hummus

Pesto

Pepperoni

Pastrami

Salami

Sour Cream

Mayonnaise

Ranch Dressing

Creamy Salad Dressing

Peanut Butter/Nuts Butter

Nuts

Seeds

Dark Chocolate

Butter

Cream Cheese

Margarine

Oil

Oil-Based Salad Dressing

Olives

Olive Oil

Coconut

Chips

Taco Shells

Please add any additional information that would be helpful to know:

Thank you!

The purpose of this questionnaire is to learn which foods you purchase and eat most frequently. Simply check off the foods that you have eaten within the last 4 months at home or at a restaurant.

Client Consent

Name *

First Name

Last Name

Consent

I agree to participate in the nutrition sessions provided by a Nutriworks, Inc. Dietitian for the previously agreed-upon fee. I understand that if I must cancel an appointment, it must be done 24 hours prior to the scheduled meeting time. Failure to do so will result in a forfeit of that session without a refund. If I have not prepaid for the session, I will remit payment when asked to do so. I understand that I must make payment for each session on the day the service is provided. If a discount applies, I agree to pay the full amount at the first session. If my check doesn’t clear for any payment, I agree to pay the $35 returned check fee. I understand that these sessions are not medically supervised and agree to consult with my physician if I have any existing medical condition. I give Nutriworks, Inc. permission to contact my physician if deemed necessary. I understand that nutritional supplementation may be recommended at any point during a session as part of my nutritional regimen and release Nutriworks, Inc. from any liability for recommending a supplement. The nutrition sessions are designed to help you reach your goal by adapting your dietary intake to your current needs in a safe environment. I understand that I cannot expect to lose more than 1-4 pounds per week resulting from the changes to my dietary intake.

The Physician that I see most regularly is: *

City and State of Physician's Office: *

Intern *

Will you allow an intern to observe your session?

Yes

Signature *

BY ENTERING MY NAME BELOW, I ELECTRONICALLY CONSENT THAT I HAVE REVIEWED AND AGREE TO ALL OF THE ABOVE STATEMENTS.

Thank you!

This is required before our first meeting.

Food Recall

Download the Food Recall form in Excel, complete and email to admin@nutriworksinc.com

Enter every meal or drink consumed within a 3 day period, preferably 2 weekdays and 1 weekend day.

The more information you provide, the more accurate we can be analyzing your food habits.

Helpers on amounts:
1 cup = fist, 3-4 oz. of meat = palm, 1 tsp. = thumb tip, 1-2 oz. snack food = handful, 1 oz. = entire thumb

Schedule an Appointment - New Clients

Primary Goals working with a dietitian *

Lose body fat and lose weight

Gain muscle mass and gain weight

Perform better

Improve my health

Current training/exercise routine *

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Office Location *

Select your preferred office location or regular follow-up method if travel is an issue.

Dallas

Fort Worth

Virtual

How did you hear about us? *

Will you come to the appointment *

Alone

With partner

Thank you! We will be in touch very soon!

Schedule an Appointment (Existing Clients)

First Name

Last Name

Email Address

Thank you!

817·371·3627

DALLAS

4480 Beltway Dr.
Addison, TX 75001
Located inside Optimum Performance Fitness

FORT WORTH

5800 Edwards Ranch Rd., Suite 200
Fort Worth, TX 76109
Located inside R4 Flow, 2nd Floor

Send all correspondence here

VIRTUAL

Anywhere in the World
We use our own Teleheath video conferencing

eve@nutriworksinc.com

Hours