Dear new client,

I would love to extend a warm and sincere welcome to you! I am so looking forward to working with you to reach your nutrition and health goals. Since this is your first consultation, I would like to take the time to get to know you better. The questions below include your medical history and questions regarding your relationship with food. The information provided assists me in providing an individual centred service to you. Please provide as much detail as you feel comfortable sharing. All information provided is confidential. None of the questions provided are compulsory. If you would like to omit any questions, please do so and continue onwards with the form.

With gratitude

Kirstin

Title ( Prof, Dr, Mr, Mrs, Miss etc)

First Name

Maiden Name

Date of Birth

Last Name

Preferred Name (For the practice to call you as)

Age

ID/ passport number

Medical Aid Details

Medical aid

Medical aid number

Medical aid plan/option

Medical aid dependent code

Main member of medical aid

Street address

Cell Phone number

Email Address

Home/work number

Next of kin

Name

Relation

Home/work number

Religion

Home language

Medical history

Past or current medical diagnosis’s that may be nutritionally significant? For example PCOS, Diabetes

Have you had any recent or past surgical procedures? Please supply the date, surgeon and hospital.

Do you experience any of the following conditions? If so please provide further detail.

Allergies - Medication, food etc

Cardiac - Hypertension, cardiovascular disease, heart failure etc

Eating disorders - anorexia nervosa, bulimia, binge eating disorder etc

Endocrine - Hypothyroidism , hyperthyroidism, PCOS, metabolic syndrome etc

Gastrointestinal - Esophagitis, peptic ulcer, celiac disease, IBS etc

Haematological - Anaemia, clotting deficiencies/ abnormalities etc

Hepatobiliary and pancreatic - Liver disease, pancreatitis, diabetes etc

Human immunodeficiency virus disease

Neurological - Stroke, epilepsy etc

Oncology - Cancers

Pulmonary - Cystic fibrosis, TB, asthma etc

Psychiatric disorders - Depression, anxiety, bipolar disorder etc

Renal - Kidney stones, Chronic kidney disease, end stage renal disease etc

Rheumatoid - Osteoarthritis, rheumatoid arthritis etc

Others

Medication history

Obstetric history (female clients)

Are you currently pregnant and or breastfeeding? If so please provide details

Do you desire a pregnancy in the near future (6 months)?

Have you had previous pregnancies? If so please provide details

Did you experience any problems during the pregnancy/ies? For example hypertension, gestational diabetes etc

Have you previously given birth? If so please provide details

Did you experience any problems during the birth/s? For example bleeding, seizures etc

How old are your children now?

Have you had any symptoms of change of life/ menopause?

Psychosocial history

What is your current occupation

What is your highest educational level?

What is your marital status?

Please provide details on your living arrangements? Do you have any dependents and if so how many.

Do you have a monthly budget for food shopping? If so please provide details

Which shops do you prefer for food shopping?

Do you smoke? If so please provide details on the quantity and frequency

Do you consume alcohol? If so please provide details on the quantity and frequency

Do you consume any recreational drugs? If so please provide details

Do you feel you have sufficient social and emotional support?

Your relationship with food and your body

How would you describe your current relationship with food?

Do you usually pick foods based on their calorie content?

Do you try to avoid foods high in fat, carbohydrates or calories?

Do you watch other people eat to determine what and how much you will eat?

Do you feel guilty when you eat to the point that you are stuffed and uncomfortable?

Do you have certain eating patterns for example 3 meals a day at a certain time?

Do you eat when you are hungry and quit when you are satisfied?

Do you make food choices based on foods you enjoy?

If you are craving a certain food do you allow yourself to have it?

Do you have forbidden foods you don’t allow yourself to have?

Do you pay attention to sensory elements of food including taste, texture and flavours?

Do you use food to soothe negative emotions such as anxiety, sadness and loneliness?

What motivates you to exercise? Cosmetic or non-cosmetic benefits

Do you speak kindly to yourself about your body and food?

Diet history

Do you follow any particular diet? For example vegan, vegetarian

What are your dietary goals in booking to see a dietitian?

What would you like to achieve from your session?

Is there anything else you would like to inform/advise or request of the practice?

Lastly, the practice would find it incredibly beneficial if you could let us know where you heard about us?

How did you here about me?

Referral

Social Media

Word of Mouth

Other

Informed consent

I consent to providing the Personal Information required, to Kirstin Sylvester Dietitians, on the understanding that Kirstin Sylvester Dietitians is responsible to abide by the principles set out in POPIA, in the business’ POPIA Policy.

I declare that all Personal Information being supplied by me to Kirstin Sylvester Dietitians is accurate, up to date, not misleading, and that it is complete in all material respects.

I undertake to advise Kirstin Sylvester Dietitians immediately of any changes to my Personal Information, should any of the details change.

By providing Kirstin Sylvester Dietitians with my Personal Information, I consent and give the Company permission to process and further process the Personal Information, as and when required, that I supply to the business, understanding the purposes for which the Personal Information is required and for which it will be used.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thank you so much for taking the time to complete this detailed form!

I look forward to partnering with you to optimise your health.

Thanks for submitting!

Medical Aid Details

Main member of medical aid

Next of kin

Medical history

Do you experience any of the following conditions? If so please provide further detail.

Medication history

Obstetric history (female clients)

Psychosocial history

Your relationship with food and your body

Diet history

Informed consent

Kirstin Sylvester
Registered Dietitian
South African Certified Lactation Consultant.

Website Design By Creative Contrast

Kirstin Sylvester 2021 | All Rights Reserved | Privacy Policy

Medical Aid Details

Main member of medical aid

Next of kin

Medical history

Do you experience any of the following conditions? If so please provide further detail.

Medication history

Obstetric history (female clients)

Psychosocial history

Your relationship with food and your body

Diet history

Informed consent

Kirstin Sylvester Registered Dietitian South African Certified Lactation Consultant.

Website Design By Creative Contrast

Kirstin Sylvester
Registered Dietitian
South African Certified Lactation Consultant.