Do you cook? Yes No. If yes, how many meals are home cooked per week on average?___________. What prevents you from able to prepare meals for yourself/family? (i.e. don't know how, no stove etc…)__________________________________________________________________ Physical Activity: How do you incorporate physical activity/exercise into your lifestyle currently? Activity # Days per Week Duration Example: Walking 3 30 minutes Does anything your ability to exercise? ______________________________________________ What questions/concerns would you like the dietitian to address?
Do you cook? Yes No. If yes, how many meals are home cooked per week on average?___________. What prevents you from able to prepare meals for yourself/family? (i.e. don't know how, no stove etc…)__________________________________________________________________ Physical Activity: How do you incorporate physical activity/exercise into your lifestyle currently? Activity # Days per Week Duration Example: Walking 3 30 minutes Does anything your ability to exercise? ______________________________________________ What questions/concerns would you like the dietitian to address?
New%20Client%20Health%20History.docx