EmailMe Form - Inner Health Nutrition Questionnaire

Client Information
Full Name *
First Last
Email Address *
Preferred Contact Number *
### - ### - ####
Would you like to be added to our complimentary nutrition newsletter? *
Yes
No
Do you consent to email/phone communications with Filomena/Inner Health? *
Yes
No
Age *
Date of Birth *
DD / MM / YYYY
Client Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Medical History: (please check all that apply and include specific details in the box below) *
Food Allergies
Food Intolerances
Elevated blood cholesterol/heart problems
Elevated blood pressure
Elevated blood sugar/Diabetes
Gastrointestinal disorders/discomfort
Liver/Kidney
Neurologic (ie.mental health)
Thyroid disorder
Bone/Joint problems
Surgeries
Nothing of Note
Other
Family Medical History (parents, siblings): *
Cardiovascular
Diabetes
Weight
Nothing of Note
Cancer
Other
Medical History Details (If you answered yes to any of the above, please provide details, such has the name of the medication and how often you take it. Please provide anything else you would like us to know below.)

Medications/Supplements

Have You Received Previous Nutrition Counselling? *
No
Yes, if yes answer the following
Where and in what setting did you receive the nutrition counselling?
Hospital Setting, Individual
Hospital Setting, Group
Community Centre, Individual
Community Centre, Group
Private
Other
What are your goals for this nutrition consultation? *
Family Physician
Family Physician Name *
Family Physician Telephone *
### - ### - ####
Family Physician's Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Do you consent to the Dietitian contacting the referring physician for additional information such as bloodwork results or medications pertaining to your nutritional care: *
Yes, I give consent to Filomena contacting my referring physician to obtain more medical information that pertains directly to my nutritional care
No, I do not give consent
Who referred you to Inner Health? *
Friend/Family Member
Google Search
Social Media
Medical Doctor/Specialist (Please Specify)
Deposit Fee
Upon form submission, you will be redirected to a secure Square gateway that will allow you to pay for your appointment deposit via major credit card. Deposits are non-refundable and will be applied to your first appointment fee.
First Appointment Deposit *
$150 Deposit Fee
By signing below you confirm that the details provided in the form are correct and you agree to pay the non-refundable deposit fee (to be applied to your first appointment) *
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