Food Questionnaire English

MDteleme Precision Health Food Questionnaire

6840 SW 40th Street, Suite 209, Miami, FL 33155

Phone : (786) 800-2430 | Fax: (305) 763-8379

Text Only: (786-442-1584)
Please complete this for as a request for MD Teleme Precision Health services. By signing this form you understand that you will be a patient who will pay privately with MDteleme Precision Medicine. This indicates that you will be paying for the service with either cash, a check, or a debit or credit card at the time of the service. We shall not submit claims to the insurance company for any of the services supplied in accordance with this agreement.
Name*
Date*

MesDíaAño
Fecha
Sex*
If female, are you currently pregnant and/or lactating?*
Age*
Picture of your ID*
Height (in cm or ft/inches)*
Current Body Weight (kg or lbs)*
Usual Body Weight (in kg or lbs)*
Do you currently smoke*

NeverYesUsed to, not anymore
How often do you consume (eg. brewed, instant, espresso) caffeinated tea (eg. green tea, black tea, Yerba mate), or other caffeinated beverages (eg, cola, energy/drinks)?:*

Never1-2cup per day3 or more cups per day
Type of coffee

EspressoRegular Coffee
1. Do you have any food allergies? If so, please list below.*
2. Do you currently experience any gastro intestinal symptoms (e.g., bloating, gas, acid reflux, constipation). If so, please list symptoms, general timing of symptoms and frequency of symptoms below*
3. Please specify whether you currently eat according to a particular diet (e.g., vegan, keto). if applicable.*
4. Are there any foods you currently don't eat or avoid eating? (Please list any foods you avoid eating as it relates to either food preferences or food intolerances or food allergies).*
5. If you take any supplements (vitamins/herbal), please list the names and the dose of each (if known).*
7. What kinds of oil(s) do you use most often at home for cooking (used for frying, baking, or making dressings and marinades Check any that apply:
Oil*

Avocado OilPalm oilCanola oilPeanut oilCoconut oilSunflower oilCorn oilSafflower oilFlaxseed oilSesame oilGrapeseed oil Hemp Seed oil Olive oil extra virgin olive oil Olive oil light (Pure or Regular)Vegetable oil Margarine Butter7. What kinds of oils do you use most often at home for cooking used for frying, baking, or making dressings and marinades Check any that apply:NUTRIGENOMI8Olive oil extra virgin olive oilOtherOlive oil light (Pure or Regular)Other
How often do you eat food that is prepared outside of your home (ie take out, restaurants, meal delivery):
Breakfast

Never1-3 times a week3 or more times a week
Lunch

Never1-3 times a week3 or more times a week
Dinner

Never1-3 times a week3 or more times a week
Current Level of Physical Activity
Describe your physical activity at work or school:*

Very Light (Sitting at the computer most of the day, or sitting at a desk)Light (Light industrial work, sales or office work that includes some light movement)Moderate (Cleaning, kitchen staff, nursing patient care, or delivering mail on foot or by bicycle)Heavy (Heavy industrial work, construction work or farming)
Describe your leisure time physical activity level:*

Very Light (Almost no activity at all) Light Walking. non-strenuous cycling or gardening approximately once a weekLight (Walking. non-strenuous cycling or gardening approximately once a week)Moderate (e.g., brisk walking, bicycling (including to work) 3-5 times per week)Active (e.g., intense walking, bicycling or sports 3-5 times a week)Very Active (Strenuous activities several times a week).
What is the typical time you wake up?*

Hora Minutos

AM/PM Option
What is the typical time you go to bed?*

Hora Minutos

AM/PM Option
How often do you wake up at night or have your sleep interrupted?*

less than once a weekonce a week2-3 times per week4-6 times per week every nightevery night
Health and Wellness Goals
What are your top nutrition and/or health goals (e.g. increased energy levels, lose weight, incorporate more plant based foods, etc?
1.
2.
3.
Please list the top 3 results of your report that you would like to focus on during your consultation.
1.
2.
3.
Additional Notes
The following are our health, sport, fertility, and plant-based panels. Each of these panels consists of 70 genetic markers and provides useful insight for weight management, nutrient recommendations, heart health, food intolerances, eating habits, and physical activity. In addition, these panels provide additional genetic information for health and wellness that focuses on areas such as inflammation and antioxidant capacity, sleep, and alcohol sensitivity.
Medical Advise Disclaimer

This meal planning program is for informational purposes only and is not intended to be used as medical advice, or to treat, diagnose, or cure any medical condition or disease. It is designed for general health and wellness purposes only and is not specific to clients who require a specific nutrition care plan based on a certain disease or condition. The meal plan is not designed, intended or appropriate to take the place of independent clinical judgment or the relationship you have with your healthcare professional, or to address any medical condition. Clients with medical conditions should not change or stop their medications or medical care without first consulting with their healthcare professional.
Please note that our test scans your DNA for genetic variants that affect your response to the foods and beverages you consume. The test does NOT predict or diagnose any disease or health condition. Please remember to see your results with your primary doctor and have a follow-up appointment with them. With information from your test results, your dietitian will be able to provide you with dietary advice tailored to your individual genetic profile.
Hours of Sevice

I understand that unusual circumstances will sometimes require office hours to be changed without notice. I understand that the pre-recorded phone message will let me know when to call back for routine requests and what to do in the event of an urgent medical need (one that does not require emergency treatment). I understand that I must call 911 in the event of a medical emergency or proceed to the nearest emergency room for treatment.
Patient Forms

I understand that an office visit may be required if I request that the provider complete certain forms for me. There may also be a nominal fee, payable in advance, to complete these forms. I understand these Requests can take up to 14 days to process.
Medical Care Certification

With my signature below, I certify that I am in the Office / Virtual Consultation (MDteleme) of Rosabel M. Bencomo M.D P.A (RMB) to receive medical service.
Signature

Limpiar
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