Please download and complete the Medical Nutrition History Form.

Once completed, Click here and attach it to an E-mail and send it to us. One of our Registered Dietitians will contact you shortly after receiving the form to schedule the initial consultation.

1. Medical Nutrition History
• Provide as much detail as possible regarding your medical history, supplements, prescription drugs, etc. that is currently available.
• Prescription medications can often impact a person's ability to gain or lose weight. Please be as accurate as possible with the name and dosage of all prescription medications.


2. Three (3) Day Diet History
• This information will be used to perform nutritional analysis that will be reviewed during the initial counseling session.
• Provide a list of all foods and liquids consumed for two (2) weekdays and one (1) weekend day.
• Estimate as closely as possible the amounts for each food and liquid.


3. Seven (7) Day Exercise History
• This information will be used to determine the number of Calories burned each day to more accurately determine your energy requirements on a daily basis.
• Provide a detailed list of all activities for each of seven (7) days.
• If you are on your feet at work, indicate how many hours you spend walking each day
• Include as must detail about the activity, the duration, and the intensity of the activity.
• If the activity was completed wearing a heart rate monitory, include the average heart rate for the duration of the exercise.

This brochure outlines the products and services currently offered by The Human Element, Inc. Please contact us for updated pricing information.

All nutrition calculations completed on the day of your assessment are based on lean body mass from a body composition analysis test. The more accurate the test results, the more accurate the nutrition recommendation starting point will be. Please download and review the body compositional analysis instructions prior to your appointment for the most successful and accurate results.