Linda S. Caley, MS, RD Nutrition Counseling P.O. Box 811 Colchester, CT fax: Last Name First Name Middle Initial

Transcription

1 Linda S. Caley, MS, RD Nutrition Counseling P.O. Box 811 Colchester, CT fax: CLIENT REGISTRATION INFORMATION (Please Print) Last Name First Name Middle Initial Street Address City ST Zip Mailing Address City ST Zip address Phone (H) (W) Cell Birth date Male/ Female Marital Status Primary Physician Phone # Who referred you? Physician Health Practitioner Friend/relative other Your Employer Your Occupation PRIMARY INSURANCE ID# Group# Policy Holder Name Policy Holder Birthdate Your Relationship to Policy holder Policy Holder Employer SECONDAY INSURANCE ID# Group# Policy Holder Name Policy Holder Birthdate Your Relationship to Policy holder Policy Holder Employer I HEREBY, 1) CERTIFY THAT I HAVE RECEIVED A COPY THE HIPAA PRIVACY NOTICE 2) AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. 3) AUTHORIZE INSURANCE PAYMENTS TO BE SENT TO THE DIETITIAN IF APPLICABLE 4) CERTIFY THAT I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED TO ME AND/OR MEMBERS OF MY FAMILY, IF INSURANCE DOES NOT REIMBURSE THE DIETITIAN. 5) CERTIFY THAT I HAVE RECEIVED AND AGREE TO THE APPOINTMENT GUIDELINES. PATIENT/GUARDIAN SIGNATURE DATE 24 HOUR CANCELLATION OF APPOINTMENTS REQUIRED TO AVOID CHARGE

2 Authorization for Release of Information (Please fill-out and sign this release form which enables me to contact your physician and/or therapist.) I (print your name), Authorize Linda Caley, MS,RD, nutrition therapist, to contact and/or release information concerning my nutrition therapy to the following physicians/therapists. Name Address Phone Number Name Address Phone Number Name Address Phone Number Signed: Parent/guardian if under 18: Date: Phone Number: Linda S. Caley, MS,RD 52 Upton Road, P.O. Box 811 Colchester, CT , fax: , Linda@caleynutrition.com, caleynutrition.com

3 caleynutrition.com Appointment Guidelines Welcome to Caley Nutrition. I look forward to helping you achieve your nutrition goals. In order to meet your needs and provide you with the best care, the following guidelines have been established. Session Length Initial sessions generally run 90 minutes. Follow-up visits are minutes. Payment and Insurance Coverage Payment is expected at the time of your session, this includes any co-payments. I accept credit cards and checks. Checks can be made payable to: Caley Nutrition I am a participating provider with several health insurance companies. If you have health insurance, your policy may offer coverage for nutrition therapy/counseling. I will be happy to assist you in determining coverage for nutrition therapy. However, please understand that it is your responsibility to pay for your nutrition session if your insurance plan does not. Cancellations Your appointment time has been set aside for you. Kindly give 24 hours notice if you need to cancel your appointment. By giving this notice, I am able to schedule someone else for the session time. Without adequate notice you will be charged for the cancellation. Telephone Calls I am available to assist you by phone or . However, if you require more than a few minutes, please consider scheduling additional session time to more thoroughly discuss your nutrition inquiries. 52 Upton Road, Colchester, CT (860) linda@caleynutrition.com

4 NUTRITION ASSESSMENT / INTAKE FORM (Please answer all questions the best you can. You may leave any questions blank that you don t feel comfortable answering. Write NA for any question that does not apply to you) Name: Date: Gender: Age: DOB: Referred by: Reason for Referral: Have you ever worked with a Nutrition Therapist/Counselor? Yes No Please list the names of any of the following professionals with whom you are currently working: Physician: Behavioral Therapist: List all medications you are currently taking: List all vitamin/mineral supplements you are taking: Date of Last Physical Exam: Recent Labs: Yes No (please bring any results to visit) MEDICAL HISTORY: please indicate whether you or a family member have/had any of the following: Disease/Condition Self Family Relationship / Treatment Diabetes Kidney Disease Cardiovascular Disease Hypertension High Cholesterol Cancer Obesity Intestinal problems Menstrual problems Osteoporosis Food Allergies/Intolerances Mental Health Issues Drug Dependency Headaches Do you drink alcohol? Yes No Number of drinks/wk: Do you smoke? Yes No Quit Amount/day: Other Medical Concerns

5 Caley Nutrition Assessment/Intake WEIGHT HISTORY: Do you weigh yourself? Yes No How often? Current Height What has been your highest weight? Age at that time lowest weight? Age at that time What would you like to weigh? Last time you weighed this? For how long? What is your family s attitude about health/weight? MENSTRUAL HISTORY (males, please skip this section) Do you currently have menstrual cycles? Yes No Have never menstruated Age began menstruating: Approximate weight at that time: Height: Date of last menstrual cycle: Average weight fluctuation during menstrual cycle: Have you ever used birth control pills? Yes No If yes, for what reason? DIETING HISTORY How many times have you tried to lose weight? Age at first attempt: Why did you try to lose weight? What have you done in an attempt to control your weight? Commercial diet programs Yes No Fad diets Yes No Diet pills Yes No Laxatives Yes No Diuretics Yes No Vomiting Yes No Food Restriction Yes No Exercise Yes No Other Yes No EATING PATTERNS Describe what hunger feels like to you: Describe what fullness feels like to you: How do you know when to stop eating? Do you usually eat when you get hungry? Yes No Do you often eat when you are not hungry? Yes No Can you tell the difference between physical hunger and emotional hunger? Yes No 2

6 Caley Nutrition Assessment/Intake Do you eat standing up? Yes No Do you eat fast? Yes No Do you eat in the car? Yes No Do you eat when lonely? Yes No Do you eat while watching TV? Yes No Do you eat when stressed? Yes No Do you eat while reading? Yes No Do you eat when bored? Yes No Do you eat while on the computer? Yes No Do you eat when anxious? Yes No Please indicate your current eating patterns, check all that apply: Eat 3 meals each day Eat 3 meals with snacks Eat continuously throughout the day Binge Binge followed by restricting food intake Binge followed by diuretics Binge followed by vomiting Binge followed by exercise Restrict food intake Restrict with diuretic use Restrict with laxative use Excessive exercise Binge followed by laxatives EATING BEHAVIORS Please check if you experience any of the following: Avoid eating a food if you do not know how it was prepared Avoid eating a food if you do not know it s nutritional content Won t eat unless you are able to exercise or purge afterward Become upset if you are unable to eat at a certain time Become upset if you eat foods other that what you planned Eat foods that are different from the rest of your family Count calories Count fat grams Count carbohydrate grams Count protein grams Count Weight Watcher points Weigh/ measure your food Cut your food into small pieces Eat faster than others Eat slower than others Refuse to eat after a certain hour Eat the same foods daily Afraid to try new foods Will not eat in front of others Hide food so others will think you ate it Hide food so you can binge Feel guilt after eating Feel ashamed of your eating Believe there are good foods / bad foods Feel food is controlling your life Other 3

7 Caley Nutrition Assessment/Intake EXERCISE HISTORY Are you currently exercising? Yes No Please Describe: Describe your past history with exercise: Do you consider yourself a compulsive exerciser? Yes No, If yes, please explain Do you have any physical conditions that limit your ability to safely exercise? Yes No If yes, please explain What are your goals for nutrition counseling? Please list and prioritize with #1 as most important Anything else you would like to share that may impact nutritional therapy? 4