Adult New Patient Form Part 3 Adult New Patient FMI Part 3 Name* First Last Date DOB Email* PHYSICAL PROFILEHeightWeightUsual weight averageDesired weight gain rangeHighest adult weightLowest adult weightUsual weight fluctuationsYesNo NUTRITION HISTORYHave you ever had a nutrition consultation?YesNoHave you made any changes in your eating habits because of health?YesNoDescribeDo you currently follow a special diet or nutritional program?YesNoCheck all that apply Yeast Free Feingold Weight management Diabetic Dairy Free Wheat Free Ketogenic Specific Carbohydrate Gluten Free Gluten Restricted Vegetarian Vegan Low Oxalate Food Allergy How often do you weigh yourself?Do you avoid any particular foods?Who does the grocery shopping in your household?Who does the cooking in your household?How many meals do you eat out per week?0-11-33-5>5Check all the factors that apply to your current lifestyle and eating habits: Fast Eater Most family meals together Erratic eating pattern Use food as a bribe or reward Eat too much Erratic mealtimes Dislike healthy food High juice intake Time constraints Low fruit/vegetable intake Eat more than 50% meals away from home High sugar/sweet intake Poor snack choices Drinks soda or diet soda Sensory issues with food Cow’s milk 1 2 3+ Picky eater Eat too little under stress Prefers cold food Caffeine intake Prefers hot food TV or videos with meals Every meal is a struggle Challenges with food served outside the home (ex. childcare) The most important thing I should change about my diet to improve my health is: SMOKINGCurrently Smoking?YesNoHow many years?Packs per day:N/A123>3Are you interested in quitting?N/AYesNoPrevious Smoking?YesNoHow many years?Packs per day:N/A123>3Rate how likely are you to quit smoking (scale from 1-5, one being likely, 5 being no interest in quiting )N/A54321Have you ever tried to stop using tobacco?N/AYesNoWhat interventions if any?2nd Hand Smoke Exposure?YesNoHow many years? ALCOHOL INTAKEHow many drinks currently per week? 1 drink =5 ounces wine, 12 ounces beer, 1.5 ounces of spiritsNone1-34-67-10>10Previous alcohol intakeYesNoneHave you ever been told you should cut down your alcohol intake?YesNoDo you every feel guilty about your alcohol consumption?YesNoHave you ever been arrested or hospitalized because of drinking?YesNoHave you ever thought about getting help to control or stop your drinking?YesNo OTHER SUBSTANCESCaffeine intakeYesNoTypeCoffeeTeaCups a day12-4>4Caffeinated Sodas or Diet Sodas IntakeYesNo12-ounce bottle/can/day12-4>4Favorite TypeAre you currently using any recreational drugs? Have you ever used IV of inhaled recreational drugs?YesNoRecreational Drug ACTIVITY List daily type and amount of activity. Type of ActivityFrequency per week / Duration in minutesType of ActivityFrequency per week / Duration in minutesType of ActivityFrequency per week / Duration in minutesType of ActivityFrequency per week / Duration in minutes PSYCHOSOCIAL Do you feel significantly less vital than you did a year ago?YesNoDo you feel significantly less vital than you did a year ago?YesNoAre you happy?YesNoDo you feel your life has meaning and purpose?YesNoDo you believe stress is presently reducing the quality of your life?YesNoNo Do you like the work you do?YesNoHave you ever experienced major losses in your life?YesNoDo you spend the majority of your time and money to fulfill responsibilities and obligations?YesNoWould you describe your experience as a child in your family as happy and secure?YesNo STRESS/COPING Have you ever sought counseling?YesNoAre you currently in therapy?YesNoIf yes describe:Do you feel you have an excessive amount of stress in your life?YesNoDo you feel you can easily handle the stress in your life?YesNoDaily Stressors: Rate on scale of 1-10, 10 being the highest stressor.Work012345678910Family012345678910Social012345678910Finances012345678910Health012345678910Other012345678910If other stress what is that stress?Do you practice meditation or relaxation technique?YesNoIf yes, how often?Check all that apply: Yoga Meditation Imagery Breathing TaiChi Prayer Other Have you ever been abused, a victim of a crime, or experienced a significant trauma?YesNo SLEEP/REST Average number of hours you sleep per night:>108-106-8<6Do you have trouble falling asleep?YesNoDo you feel rested upon awakening?YesNoDo you have problems with insomnia?YesNoDo you snore?YesNoDo you use sleeping aids?YesNo ROLES/RELATIONSHIP Maritalstatus:SingleMarriedDivorcedGay/LesbianLongTermPartnershipWidowList ChildrenWho is living in Household?Number in HouseholdTheir Employment/Occupation:Resources for emotional support? Check all that apply: Spouse Family Friends Religious/Spiritual Pets Other Are you satisfied with your sex life?YesNoUpon Submission you will be taken to Part 4. You can visit Patient Forms for each section.