Seek Medical Nutrition Therapy at DietGenics

Gender

How did you hear about us?*

Can we notify you via Text?*

Can we notify you via Phone?*

Do you consent to receive TELEHEALTH services?*

Do parents/guardians have any nutrition or health concerns?

Is there any family history of diabetes, whether on the mother’s or father’s side — for example, grandparents, uncles, aunts, or other blood relatives?

Has he/she seen a dietitian before?*

Does he/she practice sports or participate in organized physical activity?

Food allergies?*

Does he/she eat school meals or food provided at school?*

What does he/she usually eat throughout the day? Breakfast at school?

Lunch at school?

Snacks: Does he/she eat Cheetos, Doritos, Takis, and Maruchan soup?

Drinks: Does he/she drink juices, sodas, or energy drinks?

Is he/she willing to eat vegetables and fruits?

Relationship if less than 18 yo

Gender

How did you hear about us?*

Can we notify you via Text?*

Can we notify you via Phone?*

Do you consent to receive TELEHEALTH services?*

Family medical history of diabetes?

Do you have any food allergies? *