New Client Information

* Denotes Required Field

Name:
Phone Number: Proper format "555-555-5555"
Email: Proper format "name@something.com"
Address: Proper format "Street, City, State, ZIP"
Date of Birth: Proper format "00/00/0000"
Occupation:
Emergency Contact:
Relationship to Contact:
Contact Phone: Proper format "555-555-5555"
Medical History
Height: Proper format "0ft 00in"
Weight: Proper format "000 lbs"
Diabetes Mellitus Type 1? Yes No
Diabetes Mellitus Type 2? Yes No
Pregnant? Yes No
History of cardiovascular or heart disease? Yes No
When was your last blood work? Proper format "00/00/0000"
Hight blood pressure? Yes No
What is your total cholesterol? Proper format "200 mg/dL"
Elevated cholesterol? Yes No
HDL? Proper format "00 mg/dL"
LDL? Proper format "00 mg/dL"
Triglycerides? Proper format "000 mg/dL"
Current List of Medications:
Current list of Vitamins/Supplements/Herbs/Tonics:
Goals
What are your primary goals that you would like to achieve in the next 30 days?
What are your primary goals that you would like to achieve in the next 6 months?
What are your primary goals that you would like to achieve in the next year?
Any possible obstacles or challenges?
Fitness History
Current exercise regimen:
How long on a regular exercise program?
If not currently exercising, when was the last time on a regular program? Proper format "00/00/0000"
To prove you are human, what is 5 + 13? Proper format "00"
To check you are human, what do you use to smell? Proper format "word"

Anya Todd, Registered Dietitian