Intake Form – Pregnancy Nutrition

Please enter your information

Name
Age
Weeks Pregnant or Postpartum
Pre-pregnancy Weight
Current Weight
Height
Weight History (Recent loss or gain)
Weight Goal


Supplements (vitamins/minerals/herbs) List dosage and how often you take it:


How far along are you in your pregnancy?


Have you seen a registered dietitian, nutritionist or naturopath before?

YesNo


Have you dieted in the past, and if so, which diet plan have you followed?


Personal Health History: Do you have any of the following conditions?

Osteoporosis Disorder Diabetes
Irritable Bowel Hypertension Arthritis
Hypoglycemia High Cholesterol Crohns
Cancer Allergies (please list below) Others (specify below)


Physical Activity and Frequency:


Have you had changes in your appetite lately?


How many glasses of water do you drink/day?


How many cans of pop do you have/day? (Please note if pops are Diet)


How many cups of coffee do you have per day?


How many alcoholic beverages do you have per week?


Do you have any food restrictions or dislikes?


Who shops and cooks in your house?


How often do you eat out per week, and where?

How often Where
Breakfast
Lunch
Dinner


What is your biggest nutrition challenge or main concerns regarding your diet?


1) Record your food and fluid intake for three days (alternatively you can email this to jen@firststepnutrition.com)

2) Record the time you consumed the food.

3) Record the approximate portions sizes (i.e. 8oz or 1 cup, 1 fist size, 1 deck of card-size, etc.)

4) Be honest and as accurate as possible. Do not change your eating habits just because you are recording what you eat!

Start day:


Attach your recording for Day 1 here:



Attach your recording for Day 2 here:



Attach your recording for Day 3 here:



PLEASE READ AND E-SIGN THE DOCUMENT BELOW

Waiver and Acknowledgement - RD

I grant permission for Jennifer House, RD to correspond with my (or my child’s) physician(s) and other necessary health care providers (i.e. Occupational Therapist, Dietitian) to obtain information relative to nutrition treatment. I acknowledge that any information provided to me by First Step Nutrition’s RD is designed to meet my personal dietary needs. It is NOT suitable for any other individuals and will not be transferred, copied or sold to another person.

In order to benefit from the treatment prescribed by Jennifer House, I realize that it is important for me to inform either my physician or Jennifer House of any changes I make in the application of my diet. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and or Jennifer House. I will not hold my physician or First Step Nutrition’s dietitian responsible for any complication that result from my failure to comply with either of the above.

I have agreed to have my Registered Dietitian keep records of our visits and to file these in a secure and appropriate place. I agree to have the Registered Dietitian contact other Health care Professionals to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax or email.

Cancellation Policy:

Twenty-four (24) hours notice is needed to cancel/reschedule your appointment. This allows our office to seek a replacement for the office time rented. If 24 hours notice is not provided, a fee of $25.00 will be charged to you.

Thank you for your cooperation and understanding.


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By signing this form electronically, you are agreeing to the terms and conditions stated herein.