Name
*
First Name
Last Name
Email
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Cell
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Home Phone
(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
MM
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Is this your first nutritional consultation? If not, please explain your past experiences:
Age
Gender
Height
Current Weight
How many hours do you work per week?
Relationship Status
Children?
Hobbies/Activities
Please list your health concerns
Please list your current health goals that you would like to address
Do you sleep well?
Do you wake in the night? If so what time and why do you wake up? (i.e. to urinate, bad dreams, hot flashes, etc...)
How do you feel when you wake up? (rested, sick, tired, etc...)
Please select any of the symptoms you may have experienced
Please describe the frequency of any of the symptoms you have circled, and their intensity
What percentage of your food is home cooked?
Do you like to cook?
How often do you eat out?
How many meals do you eat per day?
Do you feel tired, bloated, and/or gassy after meals?
Do you drink caffeinated drinks, how much/how often?
Do you drink sodas (diet or regular)?
How much water do you drink per day?
How many bowel movements do you have per day? per week?
Do you have any food allergies or sensitivities, such as dairy or gluten intolerance?
Do you smoke? If yes, how much and how often?
Do you drink alcohol? if yes, how much and how often?
Are you currently taking:
Any other supplements?
Please list brands of supplements taken and amounts
Do you have any known allergies (medications, herbs, foods, etc...)? Please list all
Are you currently under the care of a practitioner for a specific health issue? If so what treatments are you undergoing?
Is there anything that i need to know, or that you would like me to know about your health history?
Do you enjoy sports or activities?
What types of movement do you enjoy?
How often? (days per week; hours per day)
What is the role exercise plays in your life? (e.g. stress relief, weight management, etc...)
On average, what would you rate your daily stress level? (circle one, 1 lowest, 10 highest)
