Nutrition History Form
Dr. Clyde Wilson 415-902-6639

24-hour cancellation policy: our meeting is confirmed when your credit card number is on file
•	100% of the meeting fee is charged if cancelled less than 6 hours prior to the meeting
•	50% of the meeting fee is charged if cancelled 6-24 hours prior to the meeting time
•	Please call Morgan at the Sports Medicine Institute (SMI) 650-322-2809 ext 0, or email Morgan@SMIweb.org so your credit card number (Visa, Master card, Discover) is on file.  
•	If our session is not in my Palo Alto office, payment is required in advance.  For meetings in my Palo Alto office, you can pay in advance or at the time of the meeting.
•	Please indicate if you have called Morgan at SMI to put your credit card number on file (yes or no):  

Filling out this form prior to our meeting increases the efficiency of our sessions.  You can:
•	Print and fill it in by hand and bring it with you to our first meeting
•	Or FAX it ahead of time to 650-325-6980 (let me know you sent it so I am aware)
•	Or email it ahead of time to Clyde@DrClydeWilson.com 

NOTE: The first meeting is 2 hours long, or less ideally it can be split into two 1-hour sessions no more than 1 week apart.  The third hour (2nd meeting) should be 1-2 weeks after the first 2 hours.

A.  Contact Information and your goals.
Your name:  

Phone number:  

Email:  

Address:  

Put an “X” if you believe that emotional, stress, or boredom eating is a main problem for you:  ____
If emotionally sensitive about your eating, consider scheduling an extra 1/2 hour for the consultation.

B.  Please tell me who referred you or how you heard about me:

C.  For metabolic rate estimate
Height:						Weight:				Age:			

Waist circumference:  
Triglyceride (TG) levels from your last blood lipid profile if you have it:  
HDL counts from your last blood lipid profile if you have it:  

Hours per week at the following activity levels
Low (could maintain for half a day) hours per week:  		
Moderate (could maintain for 3 hours at a time) hours per week:  	
High (could maintain for 1-2 hours at a time) hours per week:  	
Very high (could maintain for 1/2 hour at a time) hours per week: 	 
Highest (could maintain for 15 min at a time) hours per week:	
D.  Your nutritional goals: Provide details on the next page

What is motivating you to come see me right NOW?  A new diagnosis, an upcoming sports event?

Medical (e.g. LDL cholesterol, blood pressure, joints, diabetes, bone density, amenorrhea, etc):

General health (e.g. energy, sleep quality, digestion, longevity, pregnancy, etc):
If energy is low, WHEN (all the time, just in the afternoon, when you wake)?

Body-fat/weight loss
Your specific goals and time line:  

Performance (your sport, performance goal, dates of upcoming competitions):

Additional topics or questions you would like covered not listed above:

D.  Foods preferences:  Use the below chart to help you answer this question
List what foods in the below chart you DO NOT EAT in the appropriate sections, indicating the REASONS you do not eat them:

•	Allergies or other MEDICAL conflicts with these foods:

•	You do not LIKE these foods:  

•	Have NEVER eaten these foods so never thought to try them:

•	WOULD eat these foods but think they might not be healthy so stopped eating them:  

LIST YOUR FAVORITE FOODS:

Unsaturated Fats	Moderate Protein	Whole Grain Starch 	Fruit, Vegetable	
•	Avocado

•	Nuts:  Walnuts, almonds, cashews, pecans, peanuts, etc

•	Nut butters: Peanut butter, almond butter, cashew butter, soy butter
 
•	Seeds:  Flax, pumpkin, sunflower

•	Plant oil:  Olive, Canola, Safflower, Soy, Sunflower, Corn

•	Olives

•	Salmon, Sardines 

•	Soy milk, tofu 	•	Eggs (whites)

Dairy: 
•	Yogurt
•	Cottage cheese
•	Milk

•	Chicken, turkey

•	Beef, pork, lamb, etc

•	Legumes: Beans, lentils

Seafood 
•	Crustaceans: shrimp etc
•	Muscles: Clam etc
•	Fish

Also in unsaturated fats: 
•	Soy milk, tofu
•	Salmon, sardine	•	Whole grain bread, bagel, English muffin

•	High-fiber cold cereal:  Muesli, bran flakes, etc

•	High-fiber hot cereal: Oatmeal or grain mix

•	Brown, Wild rice

•	Whole grain pasta

•	Yam, potato 

•	Whole grain crackers

	DARK FRUIT
•	Berries

DARK VEGETABLES
•	Spinach
•	Mixed greens
•	Red Leaf
•	Kale, chard
•	Broccoli
•	Cauliflower
•	Beets, radish
•	Red cabbage
•	Onion, garlic
•	Zucchini
•	Carrot 
•	Tomato	

E.  Your meals and snacks
Describe the ingredients of your most frequent meals and snacks IN THE BELOW SECTIONS.
Please be as complete as possible, but no need to write portions sizes (we will discuss portions).

BREAKFASTS you commonly eat:  Please be as complete as possible, write as many as needed
•	Example:  Skim milk with bran flakes or oatmeal and a glass of OJ
•	Another example:  Eggs whites with salsa and an English muffin with butter

Your most common breakfast (list ingredients):
How often per week:

Your second most common breakfast: 
How often per week:

Additional breakfasts and how often per week:  

LUNCHES you commonly eat:  Please be as complete as possible, write as many as needed
Example:  Deli sandwich on whole grain bread with turkey or roast beef and lettuce/tomato
Another example:  Salad with dressing, rice with chicken or beef

Your most common lunch (list ingredients):
How often per week:

Your second most common lunch: 
How often per week:

Additional lunches and how often per week:  

DINNERS you commonly eat:  Please be as complete as possible, write as many as needed

Your most common dinner (list ingredients):
How often per week:

Your second most common dinner: 
How often per week:

Additional dinners:  

SNACKS you commonly eat:  Please be as complete as possible, write as many as needed
Your most common snack (list ingredients):
How often per day:

Your second most common snack: 
How often per day:

Additional snacks:  

EATING OUT:  What is your approach when eating in a restaurant or traveling?

HABITS:  Do you have any compulsive eating habits or patterns?  What foods and how often?

F.  Hydration and electrolytes
How much TOTAL WATER do you consume on an average day:  ___________________
How much of this water do you consume in the first 30 minutes of your day:
How much of this water do you consume with meals:

Fluids other than water
Fruit juice:
Coffee:
Tea (specify if this is herbal):  
Regular soda:
Diet soda or other low-cal sweetened drink:
OTHER (please specify):

How much salt would you roughly estimate that you consume and when?  Eating out often results in more salt consumption than one might realize.

G.  Meal and snack timing  
•	For each routine schedule that you have (example:  Mon and Wed are similar schedules, Tues and Thurs are similar schedules) and would like me to give you feedback on, fill in one column with the time sequence of when you wake and go to sleep, eat meals and snacks, work, and exercise.  See the example in the far left column.  Fill in your day with times independently of the example.  
•	What you call a snack versus a meal is up to you.  Generally snacks are less than half the calories of what we think of as a meal.
•	Please put the TIME RANGE that you exercise (e.g. 6-7 pm) and go to work.
•	If you don’t have enough blocks, simply enter two things in a block e.g. one block might contain “lunch 11 am, exercise 12-1 pm”.

EXAMPLE:  
Thurs & Sat	Days:  
	Days: 
 	Days:  
	Days:  
	
Wake up:  7 am

	Wake up:	Wake up:	Wake up:	Wake up:	
Snack 7 am

	

	
Exercise 7:30-9
(note time range)

	

Breakfast 9 am

	

	
Work 10-6 pm
(note time range)

	

Lunch 11 am

	

	
Snack 3 pm

	

	
Exercise 6-7 pm
(note time range)

	

Dinner 7 pm

	

	
Snack 10 pm

	

	
Sleep 12 pm

	Sleep:  	Sleep:  	Sleep:  	Sleep: