client personal information form

RD Finders and Personal TrainingRD Finders and Personal Training

Client Personal Information Form

Name _______________________________________________________

Home Address _______________________________________________________Telephone: Home_______________ Work______________ Cell________________ Preferred________Email _______________________________________________________Birth Date _________________ Sex___________ Marital Status (optional)_______________Employer ____________________________________ Occupation _____________________________Current Physician_________________________________ Phone__________________________Physician’s Address ___________________________________________________________________Referral Received [ ] Yes [ ] No If yes, Diagnosis Provided: ___________________________________Superbill Provided [ ] Yes [ ] No Date(s): __________________________Initial(s): ________________For Insurance Reimbursement Only:Social Security Number ________________________Insurance Provider ________________________________ Group/Policy #____________________Subscriber’s Name ___________________ SSI #_____________ Relationship ___________Subscriber’s Address _______________________________________________________Subscriber’s Birth Date_______________ Subscriber’s Employer________________________________Authorization (to be signed in the presence of RD Finders and Personal Training Dietitian)I. I hereby acknowledge that I have received a copy of the HIPAA privacy notice and understand my rights under the Health Insurance Portability and Accountability Act.

2400 Jordan St * Dallas, TX 75215 * 214-280-7474 * Fax 214-421-3835


II. I hereby authorize insurance and/or Medicare payments to be sent to RD Finders and Personal Training, if applicable.III. I understand I am financially responsible for services rendered to me by RD Finders and Personal Training.IV. I hereby agree to have my visits with RD Finders and Personal Training, communicated with my primary care physician.V. I understand that I am responsible for updating my physician information as it may change with RD Finders and Personal Training.

Signature_____________________________________________ Date____________________

What are your personal nutrition goals? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever worked with a Registered Dietitian? _________If yes, who:_________________________

Health Statistics:Ht ___________ Wt __________ Pre-surgery Wt: ________Goal Weight ___________ Highest Weight Since Age 18__________ Lowest ________Do you have any food allergies / intolerances? ______________________________________________________________________________________________________________Current medical and health status ____________________________________________________________________________________________________________________________________________________________________________________________________________________________Past medical history including major illness and surgery _____________________________________________________________________________________________________________________________________________________________________Medications___________________________________________________________________________________________________________________________________________________________



Vitamin / mineral supplements and herbal preparations ______________________________________________________________________________________________________________Who does the cooking? __________ Shopping? _____________What are your favorite foods? ______________________________________________________________________________________________________________Do you smoke? ___________ If yes, how many per day? _______Do you drink alcohol? _______________ If yes, what kind _______________________How often ______________________________________________ How much at a time ______________________________________Do you exercise? _______ If so, what kind of exercise? _______________________________________________________How long and how often do you exercise? _______________________________________________________How many times a week do you dine out or purchase fast food? _______________________________________________________Where do you dine out or purchase fast food? ______________________________________________________________________________________________________________What foods do you dislike? _____________________________________________________________________________________________________________________________________________________________________


client personal information form

Documents