Nutritional Assessment Request

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Please correct the field(s) marked in red below:

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Contact Information

Contact Information
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Address

Address
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Emergency Contact

Emergency Contact
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Gender

Gender
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Date of Birth (MM/DD/YYY)

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Preferred day(s) to meet (Please check all that apply)

Preferred day(s) to meet (Please check all that apply)
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Preferred time(s) to meet

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Diagnosis:  Reason for wanting to meet with Dietitian

Individual Nutrition Counseling
(Ages 12 & up) One-on-one nutrition counseling with a certified nutrition consultant or a registered
dietitian that will be tailored to the individual needs, providing education and guidance such as weight management, diabetic education and meal planning, basic sports nutrition, and heart healthy nutrition.
First session is 60-minutes. Follow-up sessions are 30 minutes.

Cost per session:
$60.00 60-minute initial consultation
$40.00 30-minute follow up consultation
Please fill out the following questionnaire to the best of your ability. The assessment will help the Registered Dietitian counsel you more appropriately and efficiently.  This questionnaire and all personal health information will be kept under the HIPPA law.
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Weight and Height Information

Weight and Height Information
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Goal in meeting with Dietitian

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Past Medical History and Chronic Disease
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Medications, Vitamin, Mineral and or Supplements

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Prior Nutrition Education

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Physical Activity

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Sleep

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Food Allergies/Intolerances

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Food Avoidances

Thank you for choosing to utilize the nutritional services provided at Ida Lee Recreation Center.
All of our nutritional staff are licensed as Registered Dietitians and have experience working with a wide range of clients.

To gain the most from your session(s), please observe the following:

All services are available by appointment only.
There are no discounts on the cost of any services unless authorized by the Fitness Manager.
Clients must pay for all services in advance.
Sessions are approximately 30-60 minutes.
To cancel a nutrition session, YOU MUST CONTACT YOUR REGISTERED DIETITIAN DIRECTLY WITHIN 24 HOURS of your scheduled session. Failure to cancel within 24 hours will result in you being charged for the session.
Clients who arrive more than 15 minutes late will be charged for the session. In addition, the registered dietitian may cancel the session.

Nutrition Assessment fees are subject to change.

By hitting the "submit" button below, you agree to the above training policies.

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