Annette Fenton Nutrition

Changing diets, changing lives

Intake Form

Please list any other health issues you'd like to discuss.
On a scale of 1 to 10, with 1 being low and 10 being high, what is your current level of stress?
What are your main stressors in life? Finances? Relationships? Self? Work? Others?
On average, how many hours do you sleep? Is it restful?
Do you smoke or drink alcohol? If so please explain.
How many glasses of water do you drink in a day?
Do you drink regular soda, diet soda, coffee or tea? If so how many glasses or cups.
Do you follow a special diet? Vegan? Vegetarian? Paleo? Keto? Please explain
Do you have any allergies or food sensitivities?
Do you have a family history of diabetes, heart disease, cancer, autoimmune disease or other illness? Please explain.
Have you had your gallbladder removed or had kidney stones?
Please list all medications & supplements you are taking
Please list what you typically eat for breakfast, lunch, dinner & snacks.
What is your current weight? What is your ideal weight?
What is your current waist size in inches ? What is your current hip size in inches?
What is your height?
Do you exercise? If so, how often & what form of exercise?
Do you work? If so, what is your occupation?
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 In order to better assist you, kindly complete this quick intake form.  Any information provided will be used for the sole purpose of conducting a nutrition consult and will be held in strictest confidence. 

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