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Fitness Programs
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Nutrition Programs
Fitness Programs
Lifestyle Services
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Virtual Interview
The Virtual Interview allows our team to do an initial assesment before you engage in any of our programs. If you do not wish to fill out this form in it's entirety, please fill out just the "Contact Information" section (in bold) and a Dietitian will contact you to complete the interview.

Contact Information
Name:
Email:
Daytime Phone:
Evening Phone:
Address:
City:
State:
Zip:       
Tell Us About Yourself
Gender:
Date of Birth
(MM DD YY):		      
Height: feet   inches
Weight: pounds
Weight
Personal Goal Weight: pounds
How soon do you expect
to reach your goal:		 Weeks   Days
Weight 6 Months Ago: pounds
Highest Weight: pounds
Lowest Weight: pounds
Weight Trend:   
Do you feel your
curent weight is:
Physician Information
Name:
Address:
Phone:
Medical Concerns
Check all that apply.
Depression Diabetes
Cancer Heart Disease
Asthma HTN
Anemia High Choletserol
Reflux Kidney Disease
Liver Disease Pregnant
Osteoporosis Breast Feeding
Nausea / Vomiting Constipation
If treated for an Eating
Disorder - How long ago?:
Known Labs: A1C:
Cholesterol:
LDL:
HDL:
Do you have any
reading difficulties:
Nutrition
What types of foods
do you usually eat:
How often do
you eat fast food:
If you use tobacco
cigarettes, chew, or
cigars per day:
If you use alcohol
drinks per day:
How often do you
eat in restaurants:
Do you have any special diet restrictions (check all that apply):
   Low Salt Low Calorie
   Wheat-Free High Calorie
   Low Fat Low Cholesterol
   Low Carbohydrate Vegetarian
   High Fiber High Protein
   No nuts/seeds/hulls
Fitness
How often do you exercise:
How long do you spend
exercising:
What type of exercise do you do (check all that apply):
   Weights Strength Training
   Cardio Competitive Sports
   Aerobics Tennis
   Swimming Skiing
   Walking Biking
   Running Pilates
   Yoga  
Do you experience any of the following during activity (check all that apply):
   Irregular Heartbeat Chest Pain
   Lightheadedness BackPain
   Leg Cramps Joint Pain
   Shortness of Breath  
List Medications, Dietary
Supplements, or Herbs:

  



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