Dietitian Intake

Dietitian Intake Form

Please complete the online form below prior to your appointment with Stephanie Boville, Registered Dietitian. Or click this link for a printable Dietitian Intake Form.

If you need to convert your height to cm or weight to kg, click these links:
Height Conversion | Weight Conversion

Virtual Dietitian Appointment

Here is the link for virtual appointments with Registered Dietitian, Stephanie Boville. https://doxy.me/stephaniebovillenutrition

Please test the link prior to your appointment (“Pre-call Test” bottom left)

Dietitian Online Intake Form

Name

Address

City, Prov

Postal Code

Home Phone

Cell Phone

Date of appointment

Goals

Height (cm)

Weight (kg)

Supplements

Daily Training Schedule or Exercise (include intensity, length of time and type of training)

Typical Daily Food/Drink Intake (example: breakfast at 8am- 3/4c plain greek yogurt, 1cup blueberries, 1 tbsp walnuts, 1c coffee with 2tbsp 5% cream and 1tsp sugar )

Consent for the Cost of Service and Personal Information

I agree to pay for all services provided; I agree to provide 24 hours notice when canceling an appointment. If I do not provide 24 hours notice of cancellation, I agree to pay our standard fee ($50) for the missed appointment; I agree to Grand River Sports Medicine Centre (GRSM) collecting, using and disclosing personal information about me as set out in GRSM’s Privacy Policy (if you would like a copy, please email cambridge@gsrm.ca)

“If athletes were given less care and more thought, the doctors might come up with some original ideas on why illness persists, why injury doesn’t clear up.

If more non-physicians – podiatrists and physiotherapists, for instance – could be induced to lend their ideas and talents, we might see a completely new approach to sports medicine.”

– Dr. George Sheehan (1975), long distance runner and one of the world’s first sports medicine physicians