Adult Nutrition Intake · R.E.S.T.O.R.E. MNT

Companion form

Your food preferences, typical day of eating, daily rhythm, and kitchen inventory are collected in a separate form: Lifestyle & Food Preferences Survey. Please complete both forms before your first appointment.

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Section 1

About You

What brings you in?

I am seeking nutrition counseling for: *

What do you hope to accomplish in our initial assessment? *

Identity

PHI-minimized form. For privacy, this form collects your first name and last initial only. Your full contact information is on file through the Business Intake form and consent paperwork.

First Name *

Last Initial *

Demographics

Birth Month & Year *

Type in whatever format feels easiest, e.g., “June 1985” or “6/1985”. We only need month and year, not the day.

Age

Height (in)

Weight (lb)

Gender Identity *

Female

Male

Non-binary

Transgender female

Transgender male

Genderqueer

Prefer not to say

Prefer to self-describe

N/A

Pronouns

she / her

he / him

they / them

she / they

he / they

Other

N/A

Occupation or primary daytime activity *

What do you do most days? This helps us understand your energy needs, meal timing, and daily structure.

Work schedule or pattern *

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Section 2

Your Current Care Team

Collaboration between your providers leads to better outcomes. Please list anyone currently supporting your health. We will only contact providers you explicitly authorize below.

🧠 Therapist / Counselor / Psychologist

Allow contact?

Provider Name

Practice / Clinic

Phone

Fax

How long have you been seeing this provider?

Less than 3 months

3–6 months

6–12 months

1–2 years

3+ years

N/A

🩺 Primary Care Doctor / Pediatrician

Allow contact?

Provider Name

Practice / Clinic

Phone

Fax

How long have you been a patient?

Less than 1 year

1–3 years

4–10 years

10+ years

N/A

💊 Psychiatrist / APRN / Prescriber

Allow contact?

Provider Name

Practice / Clinic

Phone

Fax

How long have you been seeing this provider?

Less than 3 months

3–6 months

6–12 months

1–2 years

3+ years

N/A

➕ Other Provider

Allow contact?

Provider Type

Provider Name

Practice / Clinic

Phone

Fax

How long have you been seeing this provider?

Less than 3 months

3–6 months

6–12 months

1–2 years

3+ years

N/A

Records you would like us to obtain for care coordination:

Authorization to Collaborate with Your Care Team

By signing below, I authorize Sinnergy Wellness Group to communicate with the providers I have enabled above for the purpose of coordinating my care. I understand this may include sharing session notes, nutrition assessments, and clinical progress updates. This authorization can be revoked at any time in writing.

Signature (type your full name)

Date

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Section 3

Health History

Past Medical History

Current or past medical diagnoses: *

Allergies

Food allergies:

Environmental allergies:

Medication allergies:

Surgeries & Hospitalizations

List any surgeries or hospitalizations with approximate dates:

Menstrual / Reproductive Health

Skip this section if it does not apply to you.

Last menstrual period (LMP)

Cycle regularity

Additional reproductive or hormonal health notes:

Family Medical History

Relevant family medical history:

Treatment History

Previous treatment for current issues (include dates or N/A): *

Emergency room or urgent care visits related to current issues (with approximate dates or N/A):

Recent Medical Testing

Last PCP visit

Last full bloodwork / labs

Cardiac & Bone Health Testing

✓

EKG / ECG — include date and results below

✓

Echocardiogram (Echo) — include date and results below

✓

DEXA scan (bone density) — include date, T-score, Z-score if known

Test dates and results (if applicable):

📎 Upload Health Records (Optional)

Upload any recent labs, bloodwork results, or records you'd like your dietitian to review before your first session. This saves time during your initial evaluation.

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Click to upload or drag files here

Blood work · Labs · Physician notes · PDF, JPG, PNG · Max 20MB per file

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Section 4

Medications & Supplements

Prescription Medications

List all prescription medications: *

Include name, dose, frequency, and reason. Put N/A if none.

Over-the-Counter Medications

List any OTC medications you use regularly:

Include antacids, laxatives, sleep aids, pain relievers, allergy meds, etc. Include how often.

Nutrition Supplements

List all vitamins, minerals, herbal products, powders, or probiotics:

Include brand name, dose, and frequency if known.

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Section 5

Nutrition History

Appetite & Hunger / Fullness Cues

Select Good, Fair, or Poor for each

Overall appetite

Ability to recognize hunger cues

Ability to recognize satisfaction cues

Ability to recognize fullness cues

Tolerance of your current diet overall

Details about your appetite or tolerance:

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Section 6

Fluids

For each beverage, enter how much you have and how often (e.g., "24 oz / daily" or "1 cup / 3×/week"). Leave blank if you don't drink it.

BeverageAmountFrequency

Plain water

Sparkling water

Juice

Milk

Coffee

Tea

Energy drinks

Electrolyte drinks

Soda — regular

Soda — diet

Nutrition shakes / ONS

Alcohol

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Section 7

Kitchen, Cooking & Meal Planning

Self-Assessment

How do you feel you're doing in each of the following areas? Brief descriptions are perfect.

1. Meal & Snack Planning

2. Grocery Shopping

3. Food Prepping

4. Cooking

5. Portioning

6. Packing (meals for work, school, travel)

Select All That Apply to You

✓

I can cook for myself

✓

I know my way around the kitchen

✓

I can cook without a recipe

✓

I prefer to follow recipes

✓

I don't feel confident in the kitchen

✓

I don't like to cook

✓

I don't know how to cook

✓

Someone in my household cooks for me

✓

I use a home meal delivery service (HelloFresh, Sunbasket, etc.)

✓

I often use food delivery (Uber Eats, DoorDash, GrubHub)

✓

I eat out at a restaurant more than 3× per week

✓

I prefer to eat out only occasionally

✓

I grocery shop in store

✓

I shop online / use grocery pickup or delivery

✓

I batch cook

✓

I meal prep for the week

✓

I prefer pre-portioned foods

✓

I pre-plan meals and snacks for the week

✓

I'd like to learn how to plan meals better

Additional details about cooking, shopping, or meal planning:

Meal Planning Preferences

How many meals do you like to plan for at once?

1 meal at a time

3 meals

5 meals

7 days

I don't pre-plan

I'd like to learn

N/A

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Section 8

Exercise, Sports & Activity

Please describe any physical activity you do regularly, including intentional exercise, sports, and movement that's part of your daily life (walking to work, physical job, etc.).

Frequency

Intensity

Duration per session

How do you fuel / refuel?

Frequency

Intensity

Duration

Fueling approach

Frequency

Intensity

Duration

Fueling approach

Any additional notes about activity, movement, or physical limitations:

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Section 9

Goals of Nutrition Therapy

What do you most want to work on or accomplish through nutrition counseling? Please list up to 5 goals — they can be big picture or very specific.

Is there anything specific you want us to know before your first session?