Human Diamond Nutrition

Have any questions?
Phone
(703) 437 - 3777
Email
latidjah@humandiamond.com
Office Hours
Mon. Tues. Thurs. Fri.
10am - 5pm
Sun.
1pm - 4pm
Office Location
800 Third Street, Suite 110
Herndon, VA, 20170

If you would like to request an appointment, please fill out and submit the registration and assessment form. You will be contacted by email to schedule an appointment.

Personal Information
First Name
Last Name
Email Address
Email Address (retype)
Phone
Address
City
State
Zip Code

Medical History
Age	years old
Weight	pounds
Height	feet inches
Sex	Male Female
Are you married?	Yes No
Do you have children?	Yes No
If you have children, how many?
What are the ages of your children?
List your five major complaints about your health:
What is your occupation? What kind of physical strain does your occupation produce in you? Is there anything you do not like about your job?
Provide any information about surgeries, chronic diseases, illnesses, traumas, accidents, or dental work.
List all medications and supplements you are currently taking on a regular basis.

Diet	Times per Week
How many of these foods do you eat per week?
Pasta (Number of servings the size of your fist)
Breads (Slice of bread, rice cake, cookie, piece of cake, etc. Number of single servings)
Cereals (Breakfast and snacks. Number of fist size servings)
Candy, Chocolate, Sugar (Pieces of candy and teaspoons of sugar)
Dried Fruit (Figs, raisins, dates, etc. Number of single pieces)
Grains (Wheat, millet, oatmeal, barley, corn, rye, rice etc. Number of fist size servings)
Legumes (Beans, garbanzo, lentils, peas, etc. Number of fist size servings)
Vegetables (Green, or purple, leafy vegetables. Number of fist size servings)
Fruit Juices (Number of 4 oz servings)
Fresh Fruit (Number of pieces)
Meats (Beef, lamb, pork, etc. Number of servings)
Poultry (Chicken, turkey, game birds, etc. Number of servings)
Fish and Seafood (Number of servings)
Eggs (Number of eggs)
Dairy (Milk, yogurt, white fresh cheese. Number of servings)
Butter (Tablespoons)
Tofu (Number of servings)
Salad Dressings (Store bought salad dressings. Tablespoons)
Hydrogenated Oils like Margerine (Tablespoons)
Olive Oil (Tablespoons)
Condiments (Ketchup, mayonnaise, or mustard. Tablespoons)
Nuts and Nut Butters (Like peanut butter. Tablespoons)
Coffee, Tea (Caffeinated or decaffeinated. Number of cups)
Wine and Alcohol (Number of 2 oz servings)

Fitness Evaluation
How many times per week do you exercise?	times
What is your preferred type of exercise?
What is your target heart rate when you exercise?	bpm
How long do you exercise for?	hours minutes
Describe your average physical activity during the week: