Step 2 of 3 · My Diabetes Dietitian, Inc.
Please complete all sections as thoroughly as possible. This helps your dietitian prepare for your appointment.
e.g. A1C, cholesterol, kidney function
List diagnoses, surgeries, or significant health history
If list is long, your dietitian can make a copy at your visit
In the past 2 years, would you say you:
Do you follow a special diet now?
Have you had nutrition counseling in the past?
Do you drink alcohol?
What triggers you to eat when you are not hungry? (check all that apply)
Do you exercise?
By submitting this form, you confirm the information provided is accurate to the best of your knowledge.