Nutrition form 1

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Form 1 of 2 - Lifestyle assessment form

* Indicates required field

Name *

First

Last

Email *

Date of birth *

Height *

Weight *

What is your purpose in coming here today? *

What are your main health concerns or complaints? Please list in priority. *

Have you experienced stress or trauma in the past 5 years? *

Out of 10, how stressed do you feel at this time? *

What are the major causes of your stress? Check all that apply *

financial career personal marriage health family spiritual unfulfilled expectations other

If you chose, "other", above, please elaborate *

How does your stress manifest itself? *

Do you use any coping mechanisms? *

What do you do for exercise? List type, frequency, time of day and duration *

On a scale of 1 (low) to 10 (high), how would you describe your energy levels? *

Do you experience any lulls or highs in your energy levels throughout the day? If so, at what time of day? *

How many hours on average do you sleep daily? (Include naps) *

What time do you go to sleep? What time do you wake up? *

Do you have trouble falling asleep? *

Do you have trouble staying asleep? *

Do you awaken feeling rested? *

yes no

Do you snore? *

YES NO

What is your occupation? *

Do you enjoy your work? *

yes no sometimes

How many hours each day do you work? *

At what times do you start and end work? *

Do you work shifts or a regular schedule? *

Do you smoke? If yes, how much and for how long? *

If no, does anyone in your household or workplace smoke? *

Do you wish to... *

If you wish to gain or lose weight, how much weight do you want to gain or lose? *

What is your main motivation to change your weight? *

How many hours do you spend daily, on average, driving? *

How many hours do you spend daily, on average, watching television?? *

How many hours do you spend daily, on average, reading? *

How many hours do you spend daily, on average, In front of the computer or on your smart phone or ipad? *

What are your interests and hobbies? *

Do you vacation regularly? *

When was your last vacation? *

Do you actively participate in any spiritual discipline (church, religious group, meditation, etc?) *

yes no

Medical History

Are you currently taking any medication? *

yes no

List all medications and the reason(s) for each *

zlist any vitamins, minerals, or homeopathic remedies you are currently taking and the amount/dosages *

Do you take birth control pills? *

Have you taken antibiotics in the last 5 years? *

yes no

Do you have any allergies or sensitivities? If so, please list *

Do you have anaphylaxis (life threatening allergy)? If so please describe *

Do you have any silver mercury fillings? *

Have you ever been diagnosed with an illness? If so, please explain *

Have you ever been hospitalized? If yes, for what reason? *

Have you had suregery to remove your...(check all that apply) *

Gall bladder? Tonsils? Appendix?

How often do you have a bowel movement? *

do you strain to have a bowel movement? *

yes no sometimes

Related to particular food or circumstances? *

Do you have loose bowel movements? *

yes no sometimes

Related to particular food or circumstances? *

Is there undigested food in your stools? *

Yes no sometimes

Do you use recreational drugs? If so, how often and what type? *

Have you ever been treated for drug or alcohol dependency? *

yes no

Family History

Did your mother or father have any of the following (check all that apply) *

allergies alcoholism arthritis asthma autoimmune disease cancer diabetes drug abuse gall bladder issues heart disease hypertension intestinal disease kidney dysfunction Mental illness Osteoporosis skin conditions ulcers

What about your grandparents? Check all that apply for family history for your grandparents *

allergies alcholism arthritis asthma autoimmune disease cancer diabetes drug abuse gall bladder issues heart disease hypertension intestinal disease kidney dysfunction mental illness osteoporosis skin conditions ulcers

What about your siblings? Check off any that apply for your siblings *

allergies alcoholsim arthritis asthma autoimmune disease cancer diabetes drug abuse gall bladder issues heart disease hypertension intestinal disease kidney dysfunction mental illness osteoporosis skin conditions ulcers

Other diseases in family history? Please list *

Have you experienced fungal infections (eg jock itch, athlete's foot)? If yes, please describe *

Have you experienced a decline in sexual interest? If yes, please describe *

Have you had kidney or gall stones? If yes, please describe *

Females

Are you or could you be pregnant? *

yes no

Are you.. *

pre menopausal post menopausal neither

Have you noticed any change in menses, eg. frequency, duration, flow, clotting, or other changes? If so, please specify *

Do you suffer from PMS? If yes, please describe *

Are you experiencing any menopausal symptoms? If yes, please specify *

Have you taken a bone density test? If yes, what was the result? *

Males

Have you experienced any prostate problems (frequent urination, discomfort during urination). If yes, please describe *

Dietary Habits

How many times a day do you eat your main meals, and what time of day? *

How many times a day do you eat snacks, and what times of day? *

Do you eat meals (check all that apply) *

with family home alone on the run restaurant fast food

Do you feel there are restrictions to your diet due to preferences of others such as family, roommates, etc? If yes, please explain *

How many 1/2 cup servings per day do you typically eat for 1) fresh fruit 2) dried fruit 3) canned fruit? *

How many 1/2 cup servings per day to you tpyically eat of 1) raw vegetables 2) cooked vegetables *

How many 1/2 cup servings do you typically eat in a day of whole grains? *

How many 1/2 cup servings in a day do you typically eat of protein, and what type of protein do you typically eat? *

How many 1/2 cup servings in a day do you typically eat of dairy, and what type of dairy do you typically eat? * *

Provide examples of your typical meals, including breakfast, lunch, dinner and snacks *

Which of these do you eat or use OFTEN? *

aluminum pans microwave luncheon meats artificial sweeteners refined foods (pastries, white bread, etc.) margarine fried foods cigarettes candy fast foods

Which of these do you eat or use SOMETIMES? *

aluminum pans microwave luncheon meats artificial sweeteners refined foods (pastries, white breads, pasta, etc.) margarine fried foods cigarettes candy fast foods

How many cups of water do you drink each day? *

How many cups of coffee do you drink per day? *

How many cups of tea do you drink per day? *

Please list any other drinks you have, and how many cups of each, each day, including: soft drinks (diet), soft drinks (regular), fresh fruit juices, prepared fruit juices, milk (1%, 2%, or whole), milk (skim), prepared vegetable juices, fresh vegetable juices, red wine, white wine, beer, other alcoholic drinks, bottled or spring water, herbal tea, other *

Are you a.. *

meat eater vegetarian vegan

How often do you eat meat? *

daily 3-5 times per week once a week or less

How often do you consume dairy products? *

daily 3-5 times per week once per week or less

What are your favourite foods? *

How often do you eat them? *

What foods do you crave, and how often do you eat them? *

Do you avoid certain foods? If so, why? *

Do you experience any symptoms if meals are missed? Explain. *

Do you experience any symptoms after meals? Explain. *