Nutrilicious Intake form

Personal Information

Date *

Full Name *

Date of birth *

Age *

Gender *

Street Address *

City

Country

Email *

Phone *

Home Phone Number/ Work Phone Number/ Mobile Number

Profession *

Marital Status *

Do you have children? *

If yes, how many children do you have?

Do you have any pets? *

If yes, what kind of pets?

Name of General Practitioner (Family Doctor) *

Address of General Practitioner (Family Doctor) and Phone number

e.g Keizerstraat xx / (597)xxxxxx

Health insurance *

Assuria (Aspaz)/ Self Reliance (PZS)/ Staatsziekenfonds (SZF)/ Parsasco or other

How did you hear about Nutrilicious? *

Your Health & Wellness Goals

Is there a specific health reason that brings you to the dietitian? *

What are your main health and wellness goals and/or concerns? *

What would you like to accomplish in terms of your health and wellness within the next 1 to 6 months? *

Have you previously implemented any nutrition or lifestyle changes to improve your health? If yes, please describe them. *

Did you notice any results or changes? *

Are there any obstacles or challenges you believe might make it difficult to achieve your health and wellness goals? *

Menstrual Cycle: Are you still menstruating?

If yes, do you experience any of the following symptoms before or during your period?

When was your last menstrual period?

Medications and Supplements

Are you currently receiving treatment for any medical condition? *

If yes, please list the medications you are taking for this condition:

Other prescribed medications you are taking in addition:

Vitamin, mineral, or other supplements (including probiotics, herbs, botanical ingredients, bio-identical hormones):

Allergies or sensitivities (food, medications, others):

Eating habits and food consumption

How many times per week do you eat meals outside your home or order takeout? *

Do you have breakfast every day? *

How many meals do you eat per day? *

How many snacks do you eat daily, and what are your typical snack choices? *

Do you consume alcohol? *

If yes or occasionally, please specify the type(s) of alcohol you consume

How often do you drink per day/week? *

Do you smoke? *

If yes, how many cigarettes do you smoke per day?

What is your favorite food? *

Do you get food cravings? *

If yes, at what times do these cravings usually occur?

Choose the foods and drinks you usually crave *

Other foods you crave: *

Do you eat when you are not hungry? *

If you answered yes or sometimes, what kinds of foods do you eat and why?

Are there any foods that you DO NOT eat? *

Which foods do you consume the most? *

Lifestyle, Physical Activity, Sleep Patterns

How would you rate your daily energy level? *

Do you engage in regular physical activity? If yes, please specify the type(s) of exercise and how frequently you do them. *

How would you rate your current stress level? *

What do you believe are the causes of your stress? *

What actions do you take to feel better when you're stressed? *

How many hours of sleep do you usually get per night? Do you feel rested when you wake up? Please explain. *

Do you experience any sleep problems (such as difficulty falling asleep, staying asleep, or waking up too early)? *

What are your hobbies and interests? *

Additional Information

Is there anything else you would like to share?

Informed Consent

Nutrition and physical activity are intended to promote overall health and wellness and are not a substitute for your doctor’s care or medical interventions.
All nutritional assessments, suggestions, and consultations regarding nutrition and physical activity are based on the information you provide and are not intended to diagnose, treat, or cure any disease or condition.
Any activity or part of the program may carry inherent risks related to your health condition, physical fitness, awareness, care, and the manner in which you perform them.
You agree to inform me about any activities you are unfamiliar with and to disclose any information that may limit your participation in the proposed activities.
Results and changes in your overall health and wellness may vary depending on medical conditions, medications, and your adherence to the suggested guidelines and advice.
Since your general health and wellness may change due to adjustments in diet, nutrition, and lifestyle, your physician may need to modify any prescribed medications based on lab results. It is your responsibility to discuss this with your doctor.
Never reduce or stop prescribed medications without the instruction of your doctor or healthcare provider.
Your personal and health information will remain confidential and will not be shared without your consent.
You authorize the information provided on this form and discussed during consultations to be shared with the general practitioner listed on this form, if necessary and at the discretion of the dietitian, in the interest of your overall health and wellbeing.

Wandy Soemodihardjo, BSc, Dietitian, Nutrition Coach, at Nutrilicious, reserves the right to refuse services to any individual.

By signing below, you agree to the above terms and conditions for participating in nutritional consultations with Wandy Soemodihardjo, BSc, Dietitian, Nutrition Coach.

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