Nutrition Intake Form
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Email *
First & Last Name *
Date of Birth *
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Date
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Year at MTSU *
Age
Gender
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Height *
Weight *
Primary Reason for Nutrition Consultation *
What are you hoping to take away from this consult? (i.e. tips for healthy eating on campus, meal planning/cooking/shopping skills, nutrition to support an active lifestyle, weight management, vegetarian/vegan dining, optimal health/disease prevention, other) *
Relevant medical history
Please provide any current health concerns.
Do you have any food allergies, intolerances or dietary restrictions? If yes, please explain in detail. *
Do you currently have a campus meal plan? *
At which dining hall do you eat most of your meals? *
What does your meal/snack schedule look like on a typical day? Please provide as much detail as possible. *
Are you currently on an exercise regimen? If so, please elaborate. *
Do you have any physical limitations that may impact your ability to exercise? *
By signing up for nutrition counseling, I understand that I will be meeting with my dietitian virtually using a protected Zoom platform. *
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