Erin Bushman Nutrition
Step 1: Schedule an Appointment
Call 330-760-9702 or email Erin@ErinBushman.com to schedule an appointment.
Step 2: New Client Questionnaire
Please complete the following questions before your first appointment with Erin and
click "submit" when you are finished.
If you haven't made an appointment yet, please call 330-760-9702 in order to schedule.
My first appointment is scheduled for:
Reason for Visit
My therapist/doctor/treatment center referred me.
I might have disordered eating or new eating disorder diagnosis.
I'm switching dietitians.
Date of Birth
Weight (if unknown, give an estimate)
Please indicate if you've experienced any of the following medical conditions:
Abnormal menstrual period
Bone loss, stress fractures
Dizziness and/or passing out
Hair loss and/or lanugo
Significant changes in weight
High blood pressure
Liver or gallbladder disease
Other (list below)
Please list dates, hospitalizations, or other details for boxes checked above:
Please indicate if you've experienced any of the following mental health conditions:
Eating Disorder - anorexia
Eating Disorder - binge eating disorder
Eating Disorder - bulimia
Eating Disorder - other
Excessive feelings of guilt/shame
Borderline personality disorder
Post traumatic stress disorder
Obsessive compulsive disorder
Alcohol or substance abuse
Developmental or learning disability
Thoughts of suicide
Victim of abuse
Other (list below)
Please list dates, hospitalizations (including eating disorder treatment programs), or other details from boxes checked above:
Have you participated in counseling or psychotherapy?
Yes, within the past 5 years
Yes, over 5 years ago
Current medications and supplements and estimated start date:
How much stress do you experience in a typical week, on a scale from 1-5?
1 (Little Stress)
5 (Extreme Stress)
Have you experienced any of the following stressors in the past year?
Death of a family member
Divorce or separation
Personal injury or illness
Fired at work
Change in health of family member
Gain of new family member
Change in financial state
Change or trouble with work
Begin or end school
Change in living conditions
How many hours of sleep do you get most nights?
5 hours or less
6-7 hours per night
8 hours per night
9 hours or more
Check any of the following that describe your eating patterns:
Eat less than 3 meals per day
Eat a vegetarian or vegan diet
Eat in secret
Restrict portions or avoid eating in spite of hunger
Eat an unusually large amount of food within a 2-hour period
Feel a lack of control while eating
Measure or weigh portion sizes
Frequently on and off diets
Purge calories via vomiting, pills, or exercise
In general, in the past 6 months, how important has your weight or shape been in how you feel about yourself as a person (compared to other aspects of your life)?
1 Weight/shape were not very important
2 Weight/shape played a part in how I felt about myself
3 Weight/shape were among the main things that affected how I felt about myself
4 Weight/shape were the most important factors in how I felt about myself
Which of the following contributes to your eating or weight problems:
Food as reward
Being with others
Sight and smell of food
Eating in restaurants
What would you like to change about your eating habits, if anything, and why?
For how long do you see yourself attending nutrition counseling? Consider your goals, finances, and time.
A couple visits to receive information (nutrition education)
Regular visits until I can make changes (nutrition therapy)
I'm not sure yet.
Step 3: Forms
Download a set of forms below, read, complete, and bring with you to your first appointment.
Forms for Adults 18+
Forms for Minors
Step 4: Come to Your Appointment
St Louis Office TBD
To schedule with Erin, visit
Branz Nutrition Counseling