Complete this form to request an appointment with a dietitian.
Person ID (if UK employee):
Little or no exercise
5 times/week (intense)
Daily intense or twice daily
If active, what types of activity (i.e. walking, swimming, etc.)?
Reason(s) you are requesting a consultation:
Please list your current medical conditions:
Please list any medications or supplements you take (prescription and non-prescription):
What days and times are you available for a consultation?
What kind of consultation do you prefer?
In person (at the Seaton Center)
Please choose your status:
BCTC Cooper Campus employee
How did you hear about the nutrition consultation service?
Healthtrac Rewards website
UK Health & Wellness website
Co-worker or friend
New employee orientation
Wellness on Wheels (WOW)
Contacted by Wellness Specialist regarding a Referral
Referred by a health care provider**
**Please indicate the name of your referring provider or further details below:
Do Not Fill This Out