Patient Information – Sports Dietitian

Name *

First

Last

Email *

Number *

Address *

Medical aid type and number (Only if you would like to claim back)

Date of Birth (DD/MM/YYYY) *

Weight *

Height *

Are you married/ have a partner/ single? *

Do you have kids? *

Occupation *

Do you take any supplements or vitamins? (state how much you drink of each and the type) *

Are you on any prescription medication, and what? *

Do you smoke? *

Do you drink? And how many drinks/ night and what type of drink *

Do you have a family history of any illnesses/ health problems? *

Do you have any chronic illnesses/ health problems you struggle with? *

Do you know your blood pressure? (and state the reading) *

Do you know your cholesterol level? (and state the reading) *

Do you have any allergies? (and what) *

Record below your current eating habits (From the time you wake up until you go to bed, what you ate and how much of it) *

How many times per week do you exercise, and how long is each session *

What type of exercise do you do? (run, gym, crossfit, etc.) *

Do you eat before/ during and after your exercise sessions and what? *

GOAL, what you want to achieve from the dietitian session? *

GOAL, what are you training for, any specific time in mind? *

I agree to pay consultation fees upfront. I understand that I will be billed for a consultation at the rates indicated in the practice policy. Should my medical scheme not cover the cost of this nutrition consultation, I undertake to cover any shortfall that my scheme does not cover, that may be the full amount. *

Agree

I agree to give dietitian, Hanlie Pittendrigh, consent to all information related to giving me dietary advice and give her consent to treat me with medical nutritional therapy. *

Agree

I, understand that scheduling a telehealth consultation (with Zoom) implies consent. I voluntarily consent to this and I understand the implications thereof (As mentioned in the Consent form). *

Agree

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