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Nutrition Scheduling Form
Nutrition Scheduling Information
First Name and Last Name
Pronouns
Are you currently enrolled with eligible student status at Georgia Tech?
Yes
No
Your GTID number
Your Georgia Tech email address (Please include full email address. Ex: gburdell3@gatech.edu)
What year are you?
First year
Second year
Third year
Fourth year or higher
Graduate student or higher
How did you hear about nutrition services?
Do you prefer an in-person or virtual appointment?
In-person
Virtual
What is the primary reason for your visit?
General Nutrition
Medical Nutrition Therapy
Disordered Eating
Sports Nutrition
Other (please specify)
Specified Reason
What nutrition concerns would you like to discuss? Check all that apply.
Unintentional Weight Loss
Unintentional Weight Gain
Intentional Weight Loss
Intentional Weight Gain
Abnormal Lab Values
Food Allergies
Nausea
Vomiting
Diarrhea
Constipation
Meal Planning
Nutrition Education
Appetite Changes
Food Insecurity
Chronic Condition (please specify)
Chronic Condition (specified reason)
What is your availability to meet Monday through Friday?
Leave this field blank
