Please be certain that this intake form is completed and returned to our

Nutritionists: Monica Gulisano, RD, LDN or Joanne Gardner, MS, RDN, LDN
at Duke Integrative Medicine 1 week prior to your appointment date. Fax:
(919)681-0380

Nutrition Therapy - New Client Intake Form

All information received on this form will be treated as strictly confidential. Please fill out the form
completely and accurately. This information is essential to helping the nutrition therapist to
develop a wellness program that addresses your needs, goals and interests and is safe and effective.

Appointment Date and Time:___________________________ Duke Medical Record #_________________

Have you ever been seen at Duke before?  Yes  No (IF YES, include Duke Medical Record # above.)

Demographics
First Middle Last
Name Name Name
Date of Birth Age Gender  Male  Female
Mailing Address
City, State, Zip code
Preferred phone  Home  Work  Mobile
Secondary phone  Home  Work  Mobile
Email address
Referred by
Concerns
What health and/or nutrition concerns would you like to focus on during your visit?

1.

2.

3.
Medical History
Please check “yes” for the health conditions that your doctor has diagnosed, and then record the
approximate date of onset.
Date of Date of
CONDITION Yes Onset CONDITION Yes Onset
INFLAMMATORY /
GASTROINTESTINAL AUTOIMMUNE
Irritable Bowel Syndrome  Chronic Fatigue Syndrome 
Inflammatory Bowel Disease  Rheumatoid Arthritis 
Crohn’s Disease  Lupus SLE 
Ulcerative Colitis  Frequent Infections 
Celiac Disease  Severe Infectious Disease 
Gastric or Peptic Ulcer Disease  Herpes 
GERD, reflux / heartburn  Gout 
Hepatitis C or Liver Disease  Other: 
Food Intolerance 
Other: 
RESPIRATORY MUSCULOSKELETAL / PAIN
Asthma  Osteoarthritis 
Chronic Sinusitis  Chronic pain 
Sleep Apnea  Fibromyalgia 
Bronchitis or Emphysema  Migraines 
Tuberculosis  Other: 
Other: 
CARDIOVASCULAR URINARY / REPRODUCTIVE
Heart Disease / Heart Attack  Kidney Stones 
Stroke  Urinary Tract Infections 
Elevated Cholesterol  Yeast Infection 
Irregular Heart Rate  Prostate Problem 
High Blood Pressure  Other: 
Other: 
NEUROLOGICAL / BRAIN METABOLIC / ENDOCRINE
Depression  Type 1 Diabetes 
Anxiety  Type 2 Diabetes 
Bipolar disorder  Metabolic syndrome 
ADD/ADHD  Hypoglycemia 
Multiple Sclerosis  Hypothyroidism 
Seizures  Hyperthyroidism 
Anorexia Nervosa  Polycystic Ovarian Syndrome 
Bulimia  Infertility 
Unspecified Eating Disorder  Other: 
Parkinson’s Disease 
Other: 
CANCER: Please list type(s)
DERMATOLOGICAL and treatments.
Eczema 
Psoriasis 
Acne 
Other: 
Additional health conditions your doctor has diagnosed:

Please list any previous injuries, surgeries, and hospitalizations. Provide your age and date if known.

Your Birth History:  Vaginal  C-section Were you breastfed as an infant?  Yes  No
Family History
Have any of your close relatives (parent, sibling, child grandparent) been diagnosed with the following?
Please check, describe, and provide age of onset for those that apply.
Age of
Condition Yes Family Member(s) Onset Description
Heart Disease 

High Blood Pressure 

Stroke 

Diabetes 

Cancer 

Overweight 

Food Intolerance 
Autoimmune

Disease
Oral History
Do you visit a dentist twice per year?  Yes  No

Do you have any silver/mercury amalgam fillings?  Yes  No If yes, how many?
Allergies Allergic Symptoms Experienced
Food

Medication

Supplement

Environmental
Medications and Supplements: Please list all prescription medications, nutritional supplements,
and herbs/botanicals you are currently taking.
If this information is already in the Duke Medical System, you do not need to complete this section.
Medication Name Year Started Dose Frequency Reason

Herb/Supplement Year Started Dose Frequency Reason

Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin?  Yes  No
Have you had prolonged or regular use of Tylenol?  Yes  No
Have you had prolonged or regular use of acid-blocking drugs (Zantac, Pepcid, etc.)?  Yes  No
Have you taken antibiotics > 3 times per year?  Yes  No
Have you been on antibiotics long term (> 1 month continuously)?  Yes  No
Lifestyle Information
Do you engage in physical activity on a regular basis?  Yes  No If yes, complete the table below
Activity Number of Days per Week Duration (minutes) per Session

How many hours do you sleep on weeknights? <6  6-8  8-10  10 +

How many hours do you sleep on weekends? <6  6-8  8-10  10 +
Check which apply to you:  Trouble falling asleep  Wake up during the night  Don’t feel rested

How do you handle stress? What helps you relax?

Environmental Exposures
What is your occupation?
Are you regularly exposed to any of the following?
 Cigarette smoke  Paint fumes  Perfumes  Nail Polish
 Auto exhaust / fumes  Chemicals  Dry-cleaned clothes  Hair dyes
Do you feel dizzy or get a headache when exposed to strong chemical odors or fumes?  Yes  No
If yes, please explain.

Please describe any significant past or present exposure to substances such as recreational drugs, alcohol,
or chemicals.

Nutrition History
Have you ever had an appointment with a dietitian or nutritionist?  Yes  No

Have you changed your eating habits for a health reason?  Yes  No Please describe.

Are you currently following a particular diet or nutrition plan?  Yes  No Please describe.

Do you avoid any particular foods?  Yes  No

Please explain.
Nutrition History (continued)
Do you have any adverse food reactions (intolerances or allergies)?  Yes  No Please explain.

Height: Current Weight: Usual Weight Range: Desired Weight:

Have you recently lost or gained weight?  Yes  No If yes, please describe.

Do you have or have you had an eating disorder?  Yes  No If yes, please describe.

How many meals do you eat each day? How many snacks do you eat each day?
How many meals do you buy from a restaurant or fast food per week?  0-1  2-3  4-6  >6
Do you drink alcohol?  Yes  No If yes, how many drinks per week?
Do you drink caffeinated beverages?  Yes  No If yes, how many cups per day?
Do you use any natural or artificial sweeteners?  Yes  No If yes, which ones?
What is your favorite meal?
Check all of the factors that apply to your eating habits and current lifestyle:
 Love to eat  Fast eater  Live alone or eat alone often
 Love to cook  Erratic eating patterns  Do not plan meals or menus
 Emotional eater  Eat too much  Time constraints
 Late night eater  Rely on convenience foods  Travel frequently
 Struggle with eating issues  Eat fast food frequently  Eat only because I have to
 Family members have  Make poor snack choices  Negative relationship with food
different tastes  Confused about  Dislike healthy food
 Dislike cooking food/nutrition  Don’t know how to cook

Food Diary: Please record what you eat and drink during one typical day (24 hour period).
Please be sure to include all beverages, cream and sweetener added to beverages, and condiments added to foods.
Time woke up: Bedtime:
Amount Location
Time Food / Beverage Items
(e.g. cups, oz., tsp) (Home/Away)
Food Frequency Questionnaire – How often do you eat the following?
Never or Rarely or
Food Once/wk 2x/wk 3x/wk Daily
<4x/year <4x/month

Cheese ☐ ☐ ☐ ☐ ☐ ☐
Yogurt, Kefir ☐ ☐ ☐ ☐ ☐ ☐
Cow’s Milk ☐ ☐ ☐ ☐ ☐ ☐
Milk Substitute (soy, coconut, almond, rice, or hemp seed milk ) ☐ ☐ ☐ ☐ ☐ ☐
Red Meat ☐ ☐ ☐ ☐ ☐ ☐
Pork (pork loin, pork roast, pork chops, barbecue) ☐ ☐ ☐ ☐ ☐ ☐
Processed Meat (sausage, bacon, lunch meat) ☐ ☐ ☐ ☐ ☐ ☐
Chicken ☐ ☐ ☐ ☐ ☐ ☐
Eggs ☐ ☐ ☐ ☐ ☐ ☐
Cold Water Fish (striped bass, wild Alaskan salmon, herring,
sardines, anchovies, mackerel, Alaskan halibut, Alaskan cod)
☐ ☐ ☐ ☐ ☐ ☐
Other fish or shellfish- Indicate type: ☐ ☐ ☐ ☐ ☐ ☐
Beans, Legumes
(black beans, kidney beans, white beans, lentils)
☐ ☐ ☐ ☐ ☐ ☐
Whole Soy Foods (edamame, soy nuts) ☐ ☐ ☐ ☐ ☐ ☐
Tofu, Tempeh ☐ ☐ ☐ ☐ ☐ ☐
Soy “meat alternative” (ex. Tofurkey, soy “sausage”, soy “bacon”) ☐ ☐ ☐ ☐ ☐ ☐
Berries ☐ ☐ ☐ ☐ ☐ ☐
Other Fruits- Indicate type: ☐ ☐ ☐ ☐ ☐ ☐
Cruciferous Vegetables
(cabbage, broccoli, Brussels sprouts)
☐ ☐ ☐ ☐ ☐ ☐
Green Leafy Vegetables
(e.g. spinach, kale, collards, greens)
☐ ☐ ☐ ☐ ☐ ☐
Yellow Fruits and Vegetables
(e.g. yellow peppers, corn)
☐ ☐ ☐ ☐ ☐ ☐
Other Green Fruits and Vegetables
(e.g. peas, broccoli, avocado, cucumbers)
☐ ☐ ☐ ☐ ☐ ☐
Blue/Purple Fruits and Vegetables
(e.g. blueberries, prunes, beets, purple cabbage)
☐ ☐ ☐ ☐ ☐ ☐
Red Fruits and Vegetables
(e.g. cherries, apples, tomatoes, kidney beans)
☐ ☐ ☐ ☐ ☐ ☐
Orange Fruits and Vegetables
(e.g. orange, cantaloupe, carrots, sweet potato)
☐ ☐ ☐ ☐ ☐ ☐
White/Tan Fruits and Vegetables
(e.g. onions, garlic, ginger, nuts)
☐ ☐ ☐ ☐ ☐ ☐
Turmeric, Cumin, Ginger, Rosemary, Oregano, Parsley ☐ ☐ ☐ ☐ ☐ ☐
Nuts, Nut Butters- Indicate type: ☐ ☐ ☐ ☐ ☐ ☐
Avocado, Extra Virgin Olive Oil , Canola Oil ☐ ☐ ☐ ☐ ☐ ☐
Vegetable oil (corn, sunflower, safflower, etc. – NOT olive oil) ☐ ☐ ☐ ☐ ☐ ☐
Butter, ghee ☐ ☐ ☐ ☐ ☐ ☐
White Rice ☐ ☐ ☐ ☐ ☐ ☐
White Pasta ☐ ☐ ☐ ☐ ☐ ☐
White Bread ☐ ☐ ☐ ☐ ☐ ☐
Bagels ☐ ☐ ☐ ☐ ☐ ☐
English Muffins ☐ ☐ ☐ ☐ ☐ ☐
Pancakes or Waffles ☐ ☐ ☐ ☐ ☐ ☐
 Never or Rarely or
Food Once/wk 2x/wk 3x/wk Daily
<4x/year <4x/month

Buttermilk Biscuits ☐ ☐ ☐ ☐ ☐ ☐
Chips ☐ ☐ ☐ ☐ ☐ ☐
Pretzels ☐ ☐ ☐ ☐ ☐ ☐
Popcorn ☐ ☐ ☐ ☐ ☐ ☐
Other Snack Food (crackers, Goldfish) ☐ ☐ ☐ ☐ ☐ ☐
100% Whole Wheat, Rye, Barley (whole wheat bread and pasta) ☐ ☐ ☐ ☐ ☐ ☐
Other Whole Grains (millet, quinoa, amaranth, flax, oats, brown rice) ☐ ☐ ☐ ☐ ☐ ☐
Ice Cream ☐ ☐ ☐ ☐ ☐ ☐
Pastries, cookies, cakes ☐ ☐ ☐ ☐ ☐ ☐
Juice- Indicate type: ☐ ☐ ☐ ☐ ☐ ☐
Punch, Lemonade, or Sweet Tea ☐ ☐ ☐ ☐ ☐ ☐
Diet Soda ☐ ☐ ☐ ☐ ☐ ☐
Soda (not diet) ☐ ☐ ☐ ☐ ☐ ☐
Red Wine ☐ ☐ ☐ ☐ ☐ ☐
Tea ( white, green, black) ☐ ☐ ☐ ☐ ☐ ☐
Daily Intake Summary
What type(s) of protein do you consume most days of the week? (Check all that apply.)

☐ Animal meat ☐ Beans ☐ Eggs ☐ Soy-based ☐ Dairy ☐ Nuts and seeds

How many servings of fruit do you have in a day?

How many servings of vegetables do you have in a day?

Provide an estimate of the amount of each beverage that you consume on an average day.
Circle the label that is most appropriate based on how you consume the beverage.

Water: _____ ounces, cup(s) Diet soda: _____ cup(s), can(s), liter(s) Tea: ______ cup(s)
Coffee: _____ ounces, cup(s) Non-diet soda: _____ cup(s), can(s), liter(s) Other: __________________________________
 SYMPTOM SURVEY
Patient Name:_______________________________________Date:____________________

Completing this form is particularly helpful if you have experienced persistent and bothersome symptoms from
more than one category below. Score every symptom based on your experience over the last 30 days. Start with
the first symptom and ask yourself, "Lately, have I experienced this symptom?" If you answer no or almost not at
all, then write a "0" in the corresponding field. If the answer is yes, then ask yourself if you experience the
symptom occasionally (less than 2 times in a week) or frequently (2 or more times in a week). After you have
decided on the frequency, then ask yourself if the symptom is "Severe" or "Not Severe". Using the SCALE OF
SYMPTOM POINTS listed below, write the appropriate score in the corresponding field for EVERY symptom listed.
Total the points for each category, and add all category totals to come up with the Grand Total.
SCALE OF SYMPTOM POINTS: Grand Total:
0 = Do Not Suffer From This Ever or Almost Ever
1 = Suffer OCCASSIONALLY (less than 2 times per week), is not severe
2 = Suffer FREQUENTLY (2 or more times per week), is not severe
3 = Suffer OCCASSIONALLY and is severe
4 = Suffer FREQUENTLY and is severe

CONSTITUTIONAL NASAL/SINUS MUSCULOSKELETAL

_____ Fatigue (sluggish, tired) ____ Post Nasal Drip _____ Joint Pains/Aching
_____ Hyperactive (nervous energy) ____ Sinus Pain _____ Stiff Joints
_____ Restless (can’t relax/sit still) ____ Runny Nose _____ Muscle Aches
_____ Sleepiness During Day ____ Stuffy Nose _____ Stiff Muscles
_____ Insomnia at Night ____ Sneezing _____ TOTAL (0-20)
_______ Malaise ____ TOTAL (0-20) CARDIOVASCULAR
_____ TOTAL (0-20) MOUTH/THROAT _____ Irregular Heartbeat
EMOTIONAL/MENTAL _____ Sore Throat _____ High Blood Pressure _____
_____ Depression (feelings of _____ Swollen Throat TOTAL (0-8)
hopelessness)
_____ Swelling of Lips/Tongue DIGESTIVE
_____ Anxiety (vague fears, _____ Heartburn/Esoph.Reflux
uneasiness) _____ Gagging/Throat Clearing
_____ Lesions ("Canker Sores") _____ Stomach Pains/Cramps
_____ Mood Swings (rapid _____ Intestinal Pains/Cramps
distinct changes) _____ TOTAL (0-20)
_____ Irritability LUNGS _____ Constipation
_____ Forgetfulness _____ Wheezing" (Asthma or _____ Diarrhea
_____ Lack of concentration/focus Asthma-like Symptoms) _____ Bloating Sensation
_____ TOTAL (0-24) _____ Chest Congestion _____ Gas (of Any Kind)
HEAD/EARS _____ Non-Productive Coughing _____ Nausea, Vomiting
_____ Headache (any kind) _____ Productive Coughing _____ Painful Elimination
_______ Migraine (diagnosed) _____ TOTAL (0-20) _____ TOTAL (0-36)
_____ Earache EYES
WEIGHT MANAGEMENT
_____ Ear Infection _____ Red or Swollen Eyes
_____ Record Actual Weight
_____ Ringing in Ear _____ Watery Eyes ______ Approximate Height
_____ Itchy Ears _____ Itchy Eyes _____ Fluctuating Weight
_____TOTAL (0-24) _____ Dark Circles" or "Baggy" _____ Food Cravings
SKIN _____ TOTAL (0-16) _____ Water Retention
_____ Blemishes, Acne GENITOURINARY
_____ Binge Eating or Drinking
_____ Rashes, Hives _____ Increased Urinary _____ Purging (all methods)
_____ Eczema Frequency
_____ Painful Urination _____ TOTAL (0-20)
_____ “Rosy” Cheeks
_____ TOTAL (0-16) _____ TOTAL (0-8)

Comments: