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Contact

Phone: 760-803-9279

Email: Jackiemidland@gmail.com

Location: San Diego/Carmel Valley, online or by phone

Get Connected Today

Email*

First name

Last name

Phone

Birthday

Month

Day

Year

Address

What brings you in today?

Please list any chronic conditions such as diabetes, IBS, Obesity, Heart disease, etc

List all medications

What does a normal day of eating look like for you?

Have you worked with an RD in past?

Yes

Height and Current Weight

Weight History over past 6 months?

Do you experience GI disturbances after meals?

What Diets have you tried?

List Food intolerances

List Food Allergies

Frequency of bowel movements

Briefly explain how you feel when consuming food?

Do you drink alcohol? If yes, how many glasses per night or per week

Do you drink caffeine? How many drinks per day, what type of drinks/supplements?

List any supplements/vitamins you take daily

How much water do you drink most days?

How physically active are you? How many days/week do you exercise? What type?

How long are your workouts and what intensity? 1-5 (1=easy and 5=intense

Do you practice stress management (yoga, breathing, aromatherapy, to-do list, etc)

yes

If yes, please explain

Please rate 1-5 (1 being low and 5 being high)

Mood

Sleep

Stress

Energy

Hunger

Performance

Briefly describe your scores

What does success look like for you?

What is your 6 month goal?

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