Eleni Kalogirou | Dietitian - Nutritionist

PERSONAL INFORMATION

Last Name *

First Name *

Date of Birth *

Occupation

CONTACT INFORMATION

Address

Mobile Number *

Email *

INFORMATION ABOUT YOU

Working Hours

WHours Away from Home

Height (cm) *

Current Weight (kg)

How did you hear about us?

Google

Instagram

Facebook

TikTok

Signboard

From a friend/acquaintance

Full Name

From Elsewhere

Where from?

MEDICAL HISTORY

Hematological Tests

In the most recent blood tests, are there any values that were found to be outside the normal range?

Hematocrit/Hemoglobin

Analysis Value

White Blood Cells

Analysis Value

Red Blood Cells

Analysis Value

Total Proteins/Albumin

Analysis Value

Blood Glucose

Analysis Value

Potassium

Analysis Value

Sodium

Analysis Value

Creatinine

Analysis Value

Urea

Analysis Value

Uric Acid

Analysis Value

HDL

Analysis Value

LDL

Analysis Value

Total Cholesterol

Analysis Value

Triglycerides

Analysis Value

Phosphorus/Calcium

Analysis Value

SGOT

Analysis Value

SGPT

Analysis Value

GGT

Analysis Value

Alkaline Phosphatase

Analysis Value

Amylase

Analysis Value

CRP

Analysis Value

Are you going through any of the following life stages?

Adolescence

Pregnancy

Menopause

Old Age

Cardiovascular Diseases

Hypertension

Treatment

Hypotension

Myocardial Infarction

Date

Angina Pectoris

Murmur

Stroke

Date

Valvular Heart Diseases

Heart Failure

Coronary Artery Disease

Other

Metabolic Diseases

Diabetes Mellitus

Type 1

Type 2

Treatment

Prediabetes

Hyperthyroidism

Treatment

Hypothyroidism

Treatment

Hashimoto's Thyroiditis

Treatment

Familial Hypercholesterolemia

Hypertriglyceridemia

Food Allergies/Intolerances

Gluten

Lactose

Casein

Other

Gastrointestinal Issues

Esophagitis

GERD (Gastroesophageal Reflux Disease)

Gastritis

Hiatal Hernia

Constipation

Diarrhea

Dyspepsia

IBS (Irritable Bowel Syndrome)

Ulcer

Other

Autoimmune Digestive Disorders

Crohn's Disease

GUlcerative Colitis

Celiac Disease

Diverticulosis

Sjögren's Syndrome

Other

Blood Disorders

Iron Deficiency Anemia

Iron Supplements

Yes

Mediterranean Anemia

Thalassemia

Sickle Cell Anemia

Hemophilia

Other

Other Diseases/Conditions

Osteoporosis

Rheumatoid Arthritis

Neuropsychiatric Disorders

Epilepsy

Cholelithiasis (Gallstones)

Edema

Ascites

Other

Nephropathyn

Yes

Cancer/Neoplasm

Yes

Type/Location

Date

Hospitalization/Surgeries

Yes

Details

Date

In your immediate family (first-degree relatives), is there a history of any of the following?

Type 2 Diabetes

Hypertension

Myocardial Infarction / Stroke (Cerebrovascular Accident)

Heart Disease

Cancer

Tuberculosis

Hepatitis

Hemophilia

Familial Hypercholesterolemia

Other

WEIGHT HISTORY

Minimum Body Weight in Adult Life (kg)

Maximum Body Weight in Adult Life (kg)

Typical Body Weight (kg)

Goal

Weight Gain

Weight Loss

Weight Maintenance

Special Diet Based on Medical Guidelines

Previous attempts to regulate weight

Have you made an attempt in the past to regulate your weight?

Yes

How did you make the effort?

With a Dietitian

Alone

What was your goal in kilograms?

Did you reach your goal?

Yes

How long were you able to maintain it?

What difficulties did you face in your effort to regulate your body weight?

Did it become unregulated again after your attempt to manage it? After how long?

How much does your weight concern you in your daily life?

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

When was the first time you started to be concerned about your weight?

How long have you been at your current weight?

DIETARY HISTORY

Meal pattern (how many meals, how many snacks per day?)

Do you wake up for a late-night snack?

Yes

How much time do you spend on your meals?

Where do you have your main meal?

Table

Living room/Sofa

Desk

Other

Dietary restrictions (e.g., due to fasting, religion, etc.)

Yes

Hydration: Do you drink water, and how much?

Did you follow a healthy eating pattern during your childhood?

Yes

Did your family environment pressure you regarding food?

Yes

What was your family's meal pattern? (meals, snacks)

Do you feel guilty, ashamed, or bad about yourself after eating food?

Yes

How do you manage it? (e.g., exercising, taking laxatives, etc.)

Do you eat large amounts of food without being able to stop?

Yes

Do you think intensely about the calories in the foods you eat?

Yes

Do you often go on diets?

Yes

Why?

Does the image of your body and your body fat percentage cause you anxiety?

Yes

24-hour recall

Describe in detail the meals and snacks of a typical day, mentioning the type of meal, the time it is consumed, and your level of hunger.

Breakfast

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Mid-morning snack

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Lunch

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Afternoon snack

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Dinner

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Pre-bedtime meal

1 - Not at all

2 - A little

3 - Quite a bit

4 - A lot

5 - Very much

Likes and Dislikes

You can't eat it at all

You eat it, but not with pleasure

You want to eat every day

You don't want to deprive yourself

Foods you avoid and why

Who cooks/shops?

OTHER LIFESTYLE CHARACTERISTICS

Physical Activity

Do you exercise regularly?

Yes

How many times a week do you exercise?

What type of exercise do you do, and how long do you usually exercise for?

Are you more active or sedentary during the day?

I move enough

I probably lead a sedentary lifestyle

Is your work sedentary? (e.g., office job)

Yes

Smoking

Do you smoke?

Yes

I have quit smoking

For how many years in total?

How many cigarettes per day?

How many years have you been smoke-free?

How many years did you smoke in total?

How many cigarettes did you smoke per day?

Sleep

Sleep schedule & duration

Do you fall asleep easily or with difficulty?

Easily

With difficulty

Do you wake up easily or with difficulty?

Easily

With difficulty

Do you feel like you're not getting enough sleep?

Yes

Do you suffer from insomnia?

Yes

Do you suffer from sleep apnea?

Yes

For what reasons do you want to regulate/adjust your weight?

Signature *

Digital signature

Clear Save signature

* I hereby consent to the processing of my personal data, according to the «Privacy Policy»

Medical / Dietary History