- Nutrition Connection, Inc. - U.S. Government Fitness Center Services

Christine Osterkamp - The Diet Connection: Nutrition Screening Form (Step 1)

*Please Complete The Form Below. You will be directed to make your payment after submission.

*HOLIDAY SPECIAL: $50.00 OFF REGULAR PRICE! NOW ONLY $200.00!

First Name :
Last Name :
Email Address :
Address :
City :
State :
Country :
Phone Number + Area Code :
Gender :	Select Below... Male Female
Your Age :
Date of Birth :
Your Height :
Your Weight :

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Please list any medications and supplements you take (ex: Motrin, Lipitor, multivitamin, birth control, Hydroxycut):

Medical history/problems that you have now or had in the past-please list all:

Do you smoke? Select an Option Below Yes No

If yes, how much and how often?

Do you drink alcohol? Select an Option Below Yes No

If yes, how much and how often?

Do you exercise on a regular basis? Select an Option Below Yes No

If yes, describe briefly how often, what type of exercise, and how long your session is:

Typical daily intake for breakfast:

Typical daily intake for lunch:

Typical daily intake for dinner/supper:

Typical daily intake of snacks:

Please list foods here you dislike or cant tolerate:

Have you ever tried to lose weight in the past? Select an Option Below Yes No

If yes above, what methods and/or programs did you use?

If yes, how much and how often?

How much, if any, did you lose?

How long did you keep it off?

What are your goals?

Please state who referred you to the NUCO USA Diet Connection

I agree and confirm that the information provided is honest. I have listed my medical conditions and know that I must continue to see my doctor about them. I understand that the dietitian is not qualified to make a medical diagnosis and that the recommendations given to me are not a substitute for medical advice given by my doctor. I am responsible for my own health, eating, and exercise habits. I am responsible for my decisions. There is no such thing as a miracle food, diet pill, potion, or exercise. Results will depend upon me and how much effort and consistency I put into changing my lifestyle to a healthier one.

Your Name - Serving as Your Signature of Agreement to the Statement Above: Today's Date:

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