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HPI
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Consult
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Follow up
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Initial Weight
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Current Weight
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Weight Change Since Last Visit
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Interim History
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Primary Care Provider (name/location)
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How did you find us?
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Weight History
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Weight you feel best at
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Previous program/medications
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What is your job and work schedule?
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Who lives with you?
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Medical History
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Other Medical History
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Surgical history
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Other Surgical History
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Family history (Grandparents, Parents, Siblings, Children)
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Other Family History
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Female Health
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Female History
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Nutrition
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Interim History
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What nutrition habit would you like to improve upon the most?
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Have you previously seen a registered dietitian?
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Do you restrict any foods?
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Any vitamins/minerals/supplements that you are taking?
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Do you have any diagnosed food allergies? If yes, please list.
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Do you have any food intolerances or symptoms when eating certain foods?
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What do you typically eat for breakfast?
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Lunch
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Supper
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Snacks
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Do you eat fruits, vegetables and whole grains daily?
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What do you drink throughout the day?
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Extra Nutrition Notes
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Alcohol Use
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Smoking History
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Do you use any products containing THC?
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Physical Activity
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Interim History
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Current exercise regimen
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What type of exercise do you enjoy?
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Sleep
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Mental Health
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Sleep History
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Mental Health History
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Interim History
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Interim History
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