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Dallas Dietitian Nutritionist
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4 Week Menu Patient Intake Form
4 Week Menu Patient Intake Form
First Name:
Last Name:
Date of Birth:
Today's Date:
Age:
Weight:
Height:
Allergies:
Occupation:
Marital Status:
Single
Married
Divorced
Children:
Yes
No
Illinesses:
Heart Disease
Hypertension (High Blood Pressure)
High Cholesterol
Diabetes
Renal
Other
Other:
Current Medications:
Family History Illnesses:
Heart Disease
Hypertension (High Blood Pressure)
High Cholesterol
Diabetes
Renal
Other
Breakfast Time:
Lunch Time:
Dinner Time:
Wake-up Time:
Bed Time:
Number of Meals a Day?
Number of snacks in a day?
Favorit Fruits?
Favorite Vegetables?
What are your favorite snacks? (Nuts, pretzels, chips, yogurt, chocolate, cookies, etc)
Common beverages? And, intake levels:
Daily water drinking habits:
Do you eat eggs?
Yes
No
Do you like nut butter, such as peanut or almond butter?
Yes
No
Added Sugar is found in almost all pre-packaged snacks as well as syrups, dried and canned fruits. It is important to limit intake of added sugar. How do you feel about added sugar in your diet? Do you want to avoid daily added sugar in your diet or accept some added sugar in your diet?