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.)?
Tell us why you are requesting a consultation and include any specific health or nutrition goals that you want to achieve:
Tell us what nutrition questions you have – from wondering how much protein you need, to how to cook a certain food, to making sense of the latest nutrition news. Anything goes, as long as it is nutrition-related!
Tell us what you believe are the major barriers or challenges you have to achieving your goals:
Please list your current medical conditions:
Please list any medications or supplements you take (prescription and non-prescription):
What kind of consultation do you prefer?
In person (at the Seaton Center)
What days and times are you available for a consultation (if requesting an in-person or phone consultation)?
Please choose your status:
BCTC Cooper Campus employee
Eastern State employee
ARMS (former CKMS) employee
How did you hear about the nutrition consultation service?
UK Health & Wellness website
Co-worker or friend
New employee orientation
In the Loop Newsletter
Contacted by Wellness Specialist regarding a referral
UK LiveWell Check In Event
Referred by a health care provider**
**Please indicate the name of your referring provider or further details below:
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