.::GLOBAL NUTRITION SERVICES::.

*Name

*Last Name

*Gender

Male Female

*Age

*Address

State/Province

Zip Code

Country

*EMail

Website

*Phone

Mobile Phone

Fax

For your convenience we have provided both imperial and metric measurements. Please use only one measurement system.

Height: ft/inches cm

Weight: lb kg

Goal weiht: lb kg

Have you recently lost / gained weight?

YES NO

If yes:

How much did you gain? lb kg

How much did you lose? lb kg

Over a period of months years

Do you presently have any of the following?

High Cholesterol	YES NO
High Blood Pressure	YES NO
High Blood Sugar	YES NO
Food Intolerance/Allergy	YES NO
If yes, please specify food intolerance/allergy:

Do you suffer from any other medical condition?

YES NO

If yes, please describe

List any medication that you take:
Please describe your nutritional concern:

DISCLAIMER

The nutrition advise given by Global Nutrition Services (GNS) and Gerda Richmond, RD is based on the information provided by the client / individual. The nutrition information given is meant only for the client / individual completing the forms. It is the sole responsibility of the client / individual to provide complete and accurate information. Any misinformation or omitted information may affect the nutritional assessment / advice. Any misrepresented information is solely the client’s / individual’s responsibility and Global Nutrition Services and Gerda Richmond, RD will not be liable. Global Nutrition Services and Gerda Richmond, RD provides nutrition counseling only and is not licensed to diagnose a medical condition or illness. The client / individual must consult a physician for any medical advise.