YOUR NAME
YOUR E-MAIL
YOUR FAX NUMBER

Check all that apply or fill in the information:
MALE FEMALE
AGE HEIGHT ft. in. WEIGHT lbs.
BLOOD PRESSURE /
WAIST SIZE inches. HIP SIZE

Do you have any medical conditions? YES; NO;
If yes, please check all that apply: DIABETES; HIGH CHOLESTEROL; HIGH TRIGLYCERIDES; LOW HDL; HYPERTENSION; OTHER MEDICAL CONDITION(S) PLEASE LIST

If you have high cholesterol, please list your numbers:
Total Cholesterol number: Triglycerides
HDL LDL

If you have diabetes please list your latest Fasting Glucose Hemoglobin A1C

If you test your own blood sugars, please give the lowest to highest readings:
Lowest , Highest

Please BRIEFLY LIST any other medical conditions:

Do you take medications
yes no

If yes, please check the Rx types and if possible list the names:

blood pressure Rx or fluid pills NAME(S)

cholesterol RX NAME

diabetes pills NAME(S)

insulin (check the types) 70/30 Regular Lyspro/Humalog NPH/Lente Other
Please list the usual units of insulin that you take and the times:

Other medications: Please list other medications, vitamin supplements, or herbal products that you take. NAME(S)

PLEASE CHECK ALL THAT APPLY OF YOUR FAMILY HEALTH HISTORY:
heart attack/stroke; cancer; obesity; hypertension; diabetes; gout

Check if you have a family history of cancer:
BREAST; COLON; KIDNEY/LIVER;
PANCREATIC; OVARIAN/UTERINE

FOOD PREFERENCES/EATING STYLE:
How do you know you're hungry (check all that apply):
stomach growls; feel nauseated; feel weak and shaky;
get a headache; become irritable; can't concentrate;
feel dizzy; not sure I ever feel hunger

Do you eat (check all that apply) for
hunger; emotional reasons; boredom; cravings

If you have cravings is it for (check all that apply):
sweets/sugar; salty foods; greasy/high-fat foods; crunchy foods; soft foods

Are you a fast eater?
yes or no

Are you a slow eater (chew each bite 20 times)?
yes no

LIST ANY FOOD ALLERGIES/INTOLERANCES

LIST ANY FOODS YOU WOULD NOT EAT:

HOW MANY VEGETABLES DO YOU LIKE?
less than 5; 5-10; ALMOST ALL

CHECK ANY BEANS YOU WILL EAT:
kidney beans; chickpeas; baked beans; lima beans;
butter beans; black beans; black-eyed peas; lentils; soybeans/tofu

Will you drink milk (check)
whole; low-fat; non-fat/skim;
soymilk; goat milk

Check if you eat:
RED MEAT; CHICKEN/TURKEY; FISH;
EGGS; NUTS

How often do you usually eat?
once a day 2-3 meals/day 3 meals with snacks graze all day

How much do you usually drink of the following (check based on daily average):
water none; 1 glass; 2-3 glasses; >quart; > 2 quarts; > 3 quarts

juice none; 1 glass; 2-3 glasses; >quart

milk none; 1 glass; 2-3 glasses; >quart >quart

regular soda none; 1 can; 2-3 cans; 1 liter; 1-2 liters or more

diet soda none; 1 can; 2-3 cans; 1 liter; 1-2 liters or more

Is the regular or diet soda mostly: WITH CAFFEINE OR WITHOUT CAFFEINE

coffee/tea: none; 1-3 cups; >5 cups; >10 cups; REGULAR; D'CAF

alcohol: none; daily; weekly; only on social occasions

If you drink alcohol every day, do you feel you are a problem drinker? yes no

EXERCISE: check all that apply:
My job is very physically active yes no

I exercise daily several times a week seldom

If seldom, is it due to (check all that apply) lack of time physical problems other

Email is not guranteed to be secure. If this concerns you, you may print and fax or mail to
Lifetime Nutrition Services, Inc.
119 E. Buffalo St
Ithaca, NY 14850
Fax 607-272-2366

You may e-mail the completed form OR FAX this form to 607-272-2366. It will be returned in the form it was sent (e-mail or FAX) within 1-2 weeks.