Nutrition Intake Form

Name Name First Last
Date Date / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
University Email
CWID
OSU Affiliation

OSU Affiliation Undergraduate Student Graduate Student Medical Student Resident Faculty/Staff Other
Method of Payment

Method of Payment Cash Bursar (Student Only)
1. Would you prefer in person or virtual visits?

1. Would you prefer in person or virtual visits? In-Person Virtual
2. Which Nutrition Counseling Package would you like to purchase? View Packages Here

2. Which Nutrition Counseling Package would you like to purchase? View Packages Here 1 - 1hr session 3 - 1hr sessions 6 - 1hr sessions 12 - 1hr sessions
Availability

Please mark which days and times that you ARE available to meet with a dietitian.
Preferred Days

Preferred Days Monday Tuesday Wednesday Thursday Friday
Preferred Time

Preferred Time 4pm 5pm 6pm Other (please specify) Other (please specify)
Nutrition History and Goals (Please be as detailed as possible)
Please describe your current eating habits and/or past nutrition experiences (Eating our frequency, stress eating, activity level, dieting attempts, etc.).
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
What primary goals would you like your sessions to focus on?

What primary goals would you like your sessions to focus on? Weight Management Nutrition Education Meal Planning/Recipe Building/Portion Control Managing Food and Sugar Cravings Diet Modifications related to Disease (diabetes, cholesterol, blood pressure, heart conditions, kidney disease, autoimmune disorders, etc.) Exercise Related Goals Other (please specify) Other (please specify)
What have been the biggest challenges preventing you from achieving these goals?
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
Please specify personal/family health history
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
Current medications or supplements
Maximum of 1200 characters allowed. Currently Entered: 0 characters.
Finalization

Cancellation Policy: The client must notify the trainer at least 24 hours prior to the session if he/she wishes to cancel or reschedule. If the client does not notify the trainer at least 24 hours prior to the session, he/she may knowingly forfeit that session and will not be eligible for a refund.

Expiration Notice: All personal training sessions will expire exactly one year after the date on which they were purchased. If the client does not use all of their sessions within one year, he/she knowingly forfeits the remaining sessions and will not be eligible for a refund.

Release and Indemnity Agreement: I hereby release the Board of Regents at Oklahoma State University and all its employees from all claims on account of injury which may be sustained while participating in this program, and I agree to indemnify the Board of Regents of Oklahoma State University and its employees for any claim which may hereafter be presented as a result of such injuries.
Name Name First Last
Date Date / MM / DD YYYY
Please check this box if you agree to and understand all information stated above

Please check this box if you agree to and understand all information stated above I understand and agree

Nutrition Intake Form

Nutrition Intake Form

Availability

Nutrition History and Goals (Please be as detailed as possible)

Finalization