Wellness Your Way - Nutrition and Fitness Services that work for you! Athens, Georgia , Health, Diet, Dietitian

Please fill out the following information and click the "Submit" button at the bottom of the form to send your information to Wellness Your Way!.

All fields are required. All options are checked "No" by default.

Full Name:

Telephone: Email:

What are your personal nutrition and/or fitness goals?

Do you currently follow a special diet?

Yes No

If yes, what kind?:

Reason?:

When was the last time you had a physical examination?

Have you ever had an exercise stress test:

Yes No Don't know

If yes, were the results:

Normal Abnormal

Do you take any medications on a regular basis?

Yes No

If yes, please list medications and reasons for taking:

Have you recently been hospitalized?

Yes No

If yes, please explain:

Do you smoke?

Yes No

Are you pregnant?

Yes No

Do you drink alcohol more than three times/week?

Yes No

Is your stress level high?

Yes No

Are you moderately active on most days of the week?

Yes No

Do you have:

High blood pressure?

Yes No

High cholesterol?

Yes No

Diabetes?

Yes

Do you have parents or siblings who, prior to age 55, have had:

A heart attack?

Yes No

A stroke?

Yes No

High blood pressure?

Yes No

High cholesterol?

Yes No

Do you have:

Known heart disease?

Yes No

Rheumatic heart disease?

Yes No

A heart murmur?

Yes No

Chest pain with exertion?

Yes No

Irregular heart beat or palpitations?

Yes No

Lightheadedness or do you faint?

Yes No

Unusual shortness of breath?

Yes No

Cramping pains in legs or feet?

Yes No

Emphysema?

Yes No

Asthma?

Yes No

Back pain: upper, middle, or lower?

Yes No

Other joint pain?

Yes No

If yes, please explain:

Muscle pain or an injury?

Yes No

If yes, please explain:

Are you currently active? How long have you been at this current activity level?

What kinds of activities have you done?

Have you done any strength training before, and if so what type?

Do you have any food allergies or intolerances?

Yes No

If yes, please explain:

How many meals do you regularly eat per day?

What are some common foods you eat for breakfast?

What are some common foods you eat for lunch?

What are some common foods you eat for supper?

Do you eat snacks between meals?

Yes No

If yes, how many per day?:

What foods to you most often choose as snacks?

How many meals do you eat away from home?
per week

Where are these meals eaten?

Fast Food: /week
Restaurant: /week
Other: /week

What kind of beverages do you regularly consume, and how much on an average day?

Do you experience any of the following:

Problems Sleeping?

Yes No

Sensitivity to cold?

Yes No

Loss of menstrual period or unable to have regular periods without use of birth control pills?

Yes No

Shakiness?

Yes No

Dizziness, especially when getting up?

Yes No

More frequent colds/infections?

Yes No

Problems concentrating at work / school?

Yes No

Anxiety when eating?

Yes No

Intrusive fear of gaining weight?

Yes No

Avoidance/ fear of eating high fat or high carbohydrate foods?

Yes No

Feelings of losing control when eating?

Yes No

To the best of my knowledge, the above information is true. * Note: By checking this box you personally acknowledge that the above information is true to the best of your knowledge, and accept this as a legal replacement for your signature.

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