Leigh Wagner, MS, RD

Integrative Nutritionist
Email: lwagner@kumc.edu

One’s health and well-being are influenced by many different things, including lifestyle, family history, emotional
health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us
an overall view of your general lifestyle and health habits.

New Patient Nutrition Assessment Form

First Name: __Joy Marie_____________ Middle Name: ___Rebecca______________ Last Name:
___Bongot_________________

Address: _Brgy. Gabas_______________________ City: _____Baybay________________ State: __PH___ Zip:

____6521________
Please indicate your preferred method of contact: home work cell email

Home Phone (_________)________-_________ Birth Date: _03__/_09__/__2002___ Age:

Work Phone (_________)________-_________
Cell Phone: (+63)951 – 3650 - 892
___21_______
Email address: joymarierebecca@gmail.com
Height: _5__′ _6___ ″ Weight: _85 kg______ Sex:
__F___
Blood Type (Please circle): A / AB / B / O / Unk

Occupation: __Student_____________________ Marital Status: ____Single_________________

Age of children:
Do you have children? Yes No _______N/A_____________________
Are you pregnant? Yes No Due Date: __N/A_______

With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example:
Sarah, age 7, sister

a. Joy P. Bongot / 55 / Father

b. Ma. Corazon R. Bongot / 59 / Mother

Primary Care Provider __________________________ Date of last physical exam ______________________

Other doctors or practitioners you see __________________________________________________________

Would you like to receive e-mail notifications regarding cooking classes/demonstrations? ______________

If yes, please sign ___________________________________________________________________________

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
GOALS AND READINESS ASSESSMENT
1. I would like to visit with the dietitian, today because…

__”To help manage food intake as well as to reduce my bloating and PCOS symptoms “

2. My food and nutrition-related goals are…

__”To eat right proportions of food that is necessary in my body” _
_”To lose weight within a span of 4-6 months”
__”To reduce my PCOS symptoms”

3. My overall, health goals are…

___”To achieve and maintain healthy weight” __
_”To get adequate rest daily”
“To be more physically active and proper intake of food that is necessary in the body everyday”

4. If I could change three things about my health and nutritional habits, they would be…
a. Drinking of liquor
b. Eating foods that are high in sugar and fats
c. Not getting enough sleep

5. The biggest challenge(s) to reaching my nutrition goals is/are:

a. Being busy at school
b. Time management or lack of time
c. Diet confusion
d. Right exercise to do everyday

6. In the past, I have tried the following techniques, diets, behaviors, etc. to reach my nutrition goals…
a. Intermittent fasting
b. Water therapy
c. Going to gym
d. Joining yoga and zumba classes
e. Drinking L-Carnitine and Green tea supplements (Non-laxative type)
f. Joining sports classes

On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following:

To improve your health, how ready/willing are you to…

1 2 3 4 5

Significantly modify your diet /

Take nutritional supplements each day /
Keep a record of everything you eat each day /
Modify your lifestyle (ex: work demands, sleep habits, physical activity) /
Practice relaxation techniques /
Engage in regular exercise/physical activity /
Have periodic lab tests to assess your progress /

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
PAST MEDICAL AND SURGICAL HISTORY
Please indicate whether you or your relatives* have been diagnosed with any of the following diseases or symptoms
(specify which relative and the date of diagnosis). *Relatives include: parents, grandparents, siblings.
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
Allergies (please specify type of allergy)
Anemia
Anxiety or Panic Attacks
Arthritis (osteoarthritis or rheumatoid)
Asthma
Autoimmune condition (specify type)
Bronchitis
Cancer
Chronic Fatigue Syndrome
Crohn’s Disease or Ulcerative Colitis
Depression
Diabetes (Specify: Type I, II, Prediabetes,
Gestational Diabetes)
Dry, itchy skin, rashes, dermatitis 13 years old Diagnosed by Skin Asthma
Eczema
Emphysema
Epilepsy, convulsions, or seizures
Eye Disease (please specify)
Fibromyalgia
Food Allergies or Sensitivities
Fungal Infection (athlete’s food, ringworm,
other)
Gallbladder Disease/Gallstones (specify) Father: Laparoscopic
45 years old cholecystectomy
Gout
Heart attack/Angina
Heartburn
Heart disease (specify)
Hepatitis
High blood fats (cholesterol, triglycerides)

High blood pressure (hypertension)

Hypoglycemia (low blood sugar)
Intestinal Disease (specify)
Infammatory Bowel Disease (Crohn’s or
Ulcerative Colitis)
Irritable bowel syndrome
Kidney disease/failure or Kidney stones Mother: Extracorporeal shock wave
50 years old lithotripsy
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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Lung disease (specify)
Liver disease 19 years old Diagnosed by Covid 19
and hypoxia
Mononucleosis
Osteoporosis
PMS
Polycystic Ovarian Syndrome 13 years old 2 ovaries are polycystic
Illness/Disease/Symptom Self: Relative: Describe/Specify
Age Diagnosed Age Diagnosed
Pneumonia 19 years old Diagnosed by Bilateral
Pneumonia
Prostate Problems
Psychiatric Conditions
Seizures or epilepsy
Sinusitis
Sleep apnea
Stroke
Thyroid disease (hypo- or hyperthyroid)
Urinary Tract Infection
Other (describe)
Injuries Age Describe/Specify
Back injury
Broken (specify)
Head injury
Neck injury
Other (describe)
Diagnostic Studies Age at study Describe/Specify
Barium Enema
Bone Scan
CAT Scan: Abdom., Brain, Spine (specify)
Chest X-ray
Colonoscopy or Sigmoidoscopy (specify)
EKG
Liver scan
NMR/MRI
Upper GI Series
Other (describe)
Operations Age at operation Describe/Specify
Dental Surgery 20 years old Coronectomy (impacted wisdom tooth extraction)
Gall Bladder
Hernia
Hysterectomy

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Tonsillectomy
Other (describe)

Please complete the following information concerning your family’s health history:

If Living If Deceased If Living If Deceased

Age at Age at
Age Health Cause Age Health Cause
death death
Father 55 Healthy Spouse/Partner
Mother 59 Has Kidney Children
stones and
health
maintenance
Siblings N/A

MEDICAL SYMPTOMS QUESTIONNAIRE

Rate each of the following symptoms based upon your typical health profile for the past 30 days. If you have been having recent or
somewhat severe health symptoms, please indicate that you will fill out the questionnaire for the past 48 hours.

Past 30 days Past 48 hours

Point Scale
0 – Never or almost never have the symptom
1 – Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
3 – Frequently have it, effect is not severe
4 – Frequently have it, effect is severe

HEAD

____3___Headaches
____0___Faintness
____0___Dizziness
____1___Insomnia
Total __4____

EYES

___1____ Watery or itchy eyes

___0____ Swollen, reddened or sticky eyelids

___3___ Bags or dark circles under eye

___0____ Blurred or tunnel vision

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
(does not include near or far-sightedness)

Total __4_____
EARS ___0____ Itchy ears

___0____ Earaches, ear infections

___0____ Drainage from ear

___0____ Ringing in ears, hearing loss Total __0_____

NOSE ___0____ Stuffy nose

___0____ Sinus problems

___0____ Hay fever

___0____ Sneezing attacks

___0____ Excessive mucus formation Total __0_____

MOUTH/THROAT
___1____ Chronic cough
__0____ Gagging, frequent need to clear throat
___0____ Sore throat, hoarseness, loss of voice
___0____ Swollen or discolored tongue, gums, lips
___0____ Canker sores Total ___1____

SKIN ___4____ Acne

___0____ Hives, rashes, dry skin
___4____ Hair loss
___0____ Flushing, hot flashes
___1____ Excessive sweating Total ___9____

HEART ____0___ Irregular or skipped heartbeat

___0____ Rapid or pounding heartbeat
___0____ Chest pain Total ___0____

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

LUNGS ____0___ Chest congestion

___0____ Asthma, bronchitis
___0____ Shortness of breath
___0____ Difficulty breathing Total ___0____

DIGESTIVE TRACT
___0____ Nausea, vomiting
___1____ Diarrhea
___0____ Constipation
___4____ Bloated feeling
___0____ Belching, passing gas
___0____ Heartburn
___1____ Intestinal/stomach pain Total __6_____

JOINT/MUSCLE
___0____ Pain or aches in joints
____0___ Arthritis
___0____ Stiffness or limitation of movement
___0____ Pain or aches in muscles
___4____ Feeling of weakness or tiredness Total __4_____

WEIGHT
___1____ Binge eating/drinking
___1____ Craving certain foods
___4____ Excessive weight
___0____ Compulsive eating
___0____ Water retention
____0___ Underweight Total ___6____

ENERGY/ACTIVITY
___0____ Fatigue, sluggishness
___0___ Apathy, lethargy
___0____ Hyperactivity
___1____ Restlessness Total ___1____

MIND ___1____ Poor memory

____1___ Confusion, poor comprehension
____1___ Poor concentration
____1___ Poor physical coordination
____1___ Difficulty in making decisions
____0___ Stuttering or stammering
____0___ Slurred speech
____0___ Learning disabilities Total __5_____

EMOTIONS
____1___ Mood swings
____3___ Anxiety, fear, nervousness
____1___ Anger, irritability, aggressiveness
____1___ Depression Total __6_____

OTHER ___0____ Frequent illness

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
____1___ Frequent or urgent urination
____1___ Genital itch or discharge Total ___2____

GRAND TOTAL ___48_____

MEDICATION, SUPPLEMENT, AND ANTIBIOTIC INTAKE: Please provide the

names of medications, supplements, and/or antibiotics that you are currently taking:
Medication/Supplement/ Dose Units Frequency Start Date Stop
Antibiotic Date
Example:
One-a-Day (brand) Men’s 1200 Mg Daily 08/12/2007 current
Multivitamin
1 sachet q.d/(MyPicos)/Myo-
Inositol + Folic Acid Dietary 2.00026 g Daily November 12, 2021 current
Supplement Powder
1 tab q.d / (Centrum Advance) / Not Not
Daily August 20, 2023 current
Multivitamins + Minerals specified specified
2 tab q.d / Luxxe Slim Food
500 mg daily January 1, 2020 current
Supplement

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

Are you allergic to any medications? Yes No Please list: _______________________________

Please indicate how often you have taken antibiotics during each life stage:
< 5 times > 5 times
Infancy/ Childhood /
Teen /
Adulthood /

LIFESTYLE

Physical Activity: Using the table, please describe your physical activity.

Activity Type/Intensity (low- # Days Duration

moderate-high) per week (minutes)
Stretching/Yoga Moderate 7 times/wk 90 mins
Cardio/Aerobics (walking,
Moderate 3 times/wk 120 mins
jogging, biking, etc.)
Strength-training
Moderate 4-5 time/wk 150 mins
(weight lifting, pilates, some yoga)
Sports or Leisure Moderate 3 times/wk 120 mins
Other (specify/describe)

Does anything limit you from being physically active? _____School activities sometimes _________
Indicate daily stressors and rate the level of stress from 1 (extremely low) to 10 (extremely high):
Work___3____ Family___3____Social___3____Financial___6____Health___7____ Other_______

What helps you to unwind? __Travel, Photography, Music, My Pet Dog and food_______
On average, how many hours of sleep do you get? Weekdays_4-5 hrs.______ Weekends___7-8 hrs.____
Do you smoke?: Never In the past Currently How long?__________
Alcohol use: Never In the past Currently Type/amount/frequency: __Occasionally _________
Drug use: Never In the past Currently Prefer not to discuss Type/frequency_________

WEIGHT HISTORY:
Would you like to be weighed today? Yes No
Height __5’6_____ Current Weight _85kg_____ Desired Body Weight __50kg____
Highest Adult Weight __85kg____ When? _current_____ Weight 1 year ago _72.5kg_____

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Have you had any recent changes in your weight that you are concerned about? Yes No
If yes, please explain:___Bloated and felt like gaining weight __________________________________

DIGESTIVE HISTORY
• Do you associate any digestive symptoms with eating certain foods? Yes No

•Please
explain:______N/A___________________________________________________________
 How often do you have a bowel movement? _Twice a day _

• If you take laxatives, what type/brand and how often?

__Luxxe Slim – L-Carnitine and Green Tea Extract, everyday , before meals
_________________
• Would you describe your stools are hard, soft, or loose? (circle one)
•
Please indicate how often you experience the following symptoms:
Heartburn Often Sometimes Rarely
Gas Often Sometimes Rarely
Bloating Often Sometimes Rarely
Stomach Pain Often Sometimes Rarely
Nausea/Vomiting Often Sometimes Rarely
Diarrhea Often Sometimes Rarely
Constipation Often Sometimes Rarely

DIET HISTORY
Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural,
religious or other)?
Less or possibly avoid drinking coffee
Please list any food allergies, sensitivities or intolerances __N/A_________________________________
_____________________________________________________________________________________
Who prepares the majority of your meals? _Myself__________ Who shops for food?
___Myself____________
Where do you shop for food? Grocery store and Wet and vegetable market (OPON MARKET) ________
What percent of the foods you eat are… whole __30_____% organic__40_____% convenience
___30____%
If you do, how much time do you spend cooking/preparing meals each day? ____30 mins. to 1 hr
depending the kind of food ____________

Please indicate the materials you use for cooking and food storage:

-iron -stick

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

Do you find cooking difficult? describe __________________________

INTAKE INFORMATION:
If you follow a special diet/nutritional program, check the following that apply:

Loss
___________________
Which meals do you eat regularly, check all that apply:
Supper 3pm

The nutrition/eating habits that are most challenging for me:

Eating any kinds of food according to cravings
The nutrition/eating habits that I am most pleased with:
Most pleased with high sugar foods and high carbs

Beverage Intake: Please indicate the beverages you drink, and how often you drink them. Fill in the
“Daily Amount”, “Weekly Amount”, and/or “Monthly Amount”
Weekly
Beverage Type Daily Amount Monthly Amount
Amount
Example:
2 – 8 oz cups __ __
Coffee: X reg decaf latte
Water: 2.1 Liters __ __
6 oz (1 cup) __ __
Tea: what type(s):_Lipton Green Tea 6 oz (1 cup) __ __
__ __ __
__ __ __
6 oz (1 cup) __ __
Milk alternative Type_____________ __ __ __
__ __ Not specified

Other _________________________

Food Intake: Please indicate the frequency that you eat the following:
2-3 2-3 2-3
How often do you eat: Never 1 time/week 1 times/day
times/mo. times/week time/day
Fast food /
Restaurant food /
Vending machine food /

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Revised August 2011
 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu
Cafeteria or buffet food /
Frozen meals /
Home-cooked meals /
Leftovers /
Beef (hamburger, steak, etc.) /
Pork (chop, loin, ham, bacon, etc.) /
Liver /
Lamb /
Poultry (chicken, turkey, etc.) /
Deli meat, type: (chorizo) /
Fish, type: (bangus and etc…) /
Soyfoods, type: (tofu and etc…) /
Beans, type: (string beans and etc…) /
Crackers, type: (plain crackers) /
Cookies, cakes, muffins /
Whole grains, type: (Wheat ) /
Fresh/Raw vegetables /
Cooked vegetables /
Fruit, fresh or frozen /
Canned Vegetables or Fruit /
Margarine /
Dairy (Milk, yogurt, cheese, butter) /
French fries /
Fried meat (chicken, fish) /
Foods with added sweeteners/sugar,
/
type:
Artificial sweeteners, type: (equal
/
brand)
Meal Replacements, type: (whey
/
shake)

Food cravings:
Ice cream, banana, grapes and oranges

Food dislikes
_N/A______________________________________

Eating Style: Based on how you eat on a regular basis, please check all that apply:

-eater

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 Leigh Wagner, MS, RD
Integrative Nutritionist
Email: lwagner@kumc.edu

Travel frequently

The food/nutrition questions that I would like to ask are:

a. What kind of foods I need to intake for my diet?
b. Can I continue drinking laxative type of food supplements even though I am diagnosed of having
PCOS?
c. Is intermittent fasting a healthy option for me even though I have a lot of time going to school
and other personal activities?
d. What plans or programs you want to suggest for me to lose weight despite having PCOS?

Head circumference: 57cm

Mid-arm circumference: 31cm
Chest circumference: 103cm
Hips circumference:101cm
Waist circumference: 93cm
BMI: 30.32 – obese (grade 1)
VS:
a. BP – 110/80
b. PR - 80 bpm
c. RR – 18 bpm
d. Temp- 36.5 ˚C

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