Patient Questionnaires

We ask that all new patients fill out a background questionnaire prior to seeing the dietitian. This information helps the dietitian determine what type of nutrition education would be most appropriate for you. To save time, you may want to print out and complete the questionnaire before arriving to our office. Once you have scheduled an appointment, our office staff can assist you in determining which questionnaire would be appropriate for you to fill out. Please bring the completed questionnaire with you to your scheduled appointment. Feel free to call the office at (314) 251-8885 with questions.

• General Background Questionnaire (for most nutrition consultation appointments, usually adult patients)
• Pediatric Background Questionnaire (for pediatric patients, usually age 18 or younger)
• Prenatal Background Questionnaire (for pregnant women seeing the dietitian for an individual appointment)
• Prenatal Background Questionnaire for Gestational Diabetes Program (for pregnant women attending the Gestational Diabetes Management Program at St. John's Mercy Medical Center)
• Diabetes Management Program Questionnaire (for patients attending the Diabetes Management Program at St. John's Mercy Medical Center)
  

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615 S. New Ballas Rd., St. Louis, Missouri, 63141