Client Login
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Username:
*
Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.
E-mail address:
*
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
Mobile Phone:
Work Phone:
Home Phone:
Address
Street:
Additional:
City:
State / Province:
Country:
United States
Postal code:
Gender:
- None -
M
F
Age:
- None -
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Birthdate:
Year:
1912
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Month:
Jan
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Day:
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Height:
Current Weight:
lbs
Goal Weight:
lbs
How did you hear about Middleberg Nutrition:
Medical Information
Medical Conditions:
Prescription Medications:
Primary Care Physician:
Specialty Physicians:
Suffer from any of these conditions?:
Acid Reflux
Constipation
Gas
Bloating
Diarrhea
Nausea
Headaches
High Cholesterol
High Blood Pressure
Low Blood Sugar
High Blood Sugar
Nutritional Profile
Goals:
Weight loss
Weight Gain
Pre/Post Natal
Overall Health & Wellness
Sports Nutrition
Food Allergy
GI problems (Acid reflux, gas, bloating, constipation,)
Reduce cholesterol/blood pressure/blood sugars
Other, please list
If "other", please specify:
Have You Ever Seen a Nutritionist:
- None -
Yes
No
Which diets have you tried in the past?:
Weight watchers
Atkins
South Beach
Zone
Meal Delivery
Other, please list
If "other", please specify:
Do you take any supplements?:
Do you have any food allergies?:
What are your favorite foods?:
What foods to you dislike?:
What common restaurants do you eat at/take-in?:
Nights per week you cook or eat home-cooked meals?:
Places where you shop for groceries:
- None -
Food Emporium
A&P
Fairway
Whole Foods
Trader Joes
Costco
Shop N Shop
Wegmans
Other
If "other", please specify:
One food or beverage item you cannot live without:
Food Recall
Typical Breakfasts:
Order
-2
-1
0
1
2
-2
-1
0
1
2
-2
-1
0
1
2
Morning Snack:
Order
-1
0
1
-1
0
1
Lunch:
Order
-2
-1
0
1
2
-2
-1
0
1
2
-2
-1
0
1
2
Afternoon Snack:
Order
-2
-1
0
1
2
-2
-1
0
1
2
-2
-1
0
1
2
Dinner:
Order
-2
-1
0
1
2
-2
-1
0
1
2
-2
-1
0
1
2
Night Snack:
Order
-1
0
1
-1
0
1
Middleberg Nutrition Policies
Consent for Care and Patient Confidentiality
I grant permission to Stephanie Middleberg, RD to perform assessments and provide recommendations as are considered necessary or advised for my diagnosis. I understand that all records will be kept confidential and will not be released to others without my consent. I am willfully accepting medical nutrition therapy from Stephanie Middleberg, RD.
Cancellation Policy:
In order to best serve clients, Middleberg Nutrition requires a minimum of 24-hours notification for cancelled appointments. This provides adequate time to fill that slot with clients who are waiting for that time. Clients who do not cancel at least 24 hours in advance of their scheduled appointment will be charged in full.
Payment Information:
Middleberg Nutrition accepts cash, credit cards and checks at the time of service. Receipts can be requested so you can submit to your insurance company. Each insurance provider is different. Some may partially or fully cover the nutrition services you received and directly reimburse you.
Yes, I agree to the policies
