Julie Tang Nutrition

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Intake form

Welcome! I am so excited you’ve made the decision to improve your wellbeing and quality of life through nutrition therapy. I find it very helpful to learn a little bit about you prior to our first session. This helps me better understand your needs, preferences, and goals in order to offer realistic and personalized care for your health concerns. For any questions that are applicable, you can write “N/A”.

Instructions: Please complete this intake form and a three-consecutive-day food log at least 24 hours before our appointment. You may input your food log here or email it to me. If you have any questions, please reach out at JulieRDNutrition@gmail.com.

Thank you for your response. ✨

Name(required)

Current height and weight(required)

Any recent weight changes?(required)

Rate your current perceived level of stress on a scale of 1-10 (1 is lowest, 10 highest):(required)

Do you experience any of these gastrointestinal symptoms regularly? (select all that apply)(required)

Gas Nausea Constipation Acid reflux Bloating Diarrhea Abdominal pain None of these

Do you experience any of these symptoms regularly? (select all that apply)(required)

Brittle nails Hair loss Thinning hair Bleeding gums Altered tastes

Food aversions and/or foods you dislike?(required)

Who do you live with?(required)

Who prepares the food at home?(required)

Who grocery shops?(required)

How many meals do you eat in a day? Around what times?(required)

How many snacks do you eat in a day? Around what times?(required)

Commonly eaten foods and drinks at breakfast? lunch? dinner?(required)

Commonly eaten snacks?(required)

Common food/drink cravings?(required)

Average water intake per day?(required)

Do you have any cultural or religious food preferences or practices? If yes, please describe.(required)

On average, how many meals are from restaurants in a week?(required)

Do you smoke and/or drink alcohol? If yes, how often?(required)

Do you regularly use any of the following: (select all that apply)(required)

Artificial sweeteners Antacids Appetite stimulants Pain meds Laxatives or stool softeners Chewing gum/mints None of these

Average # hours of sleep per night:(required)

Tell me about your current exercise habits/routine:(required)

Please feel free to share any additional information here.

If you choose to input your three-day food log here, please type it below. Or you may email it to me.

Thank you for completing this!

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Thank you for your response. ✨

Name(required)

Email(required)

Message

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Let’s chat

Questions, comments or requests?
Feel free to reach out, we’d love to hear from you.

info@JulieTangNutrition.com

If you’re ready to get started with a consultation,
click HERE to be redirected to the inquiry form.

Julie Tang Nutrition

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