Do You Have Any Known Health Problems?______

NAME______M/F BIRTHDATE______DATE______

ADDRESS______

PHONE #______EMAIL______

Height______Weight______Pant Size______

Primary Doctor______

Address______

Phone Number______

Fax Number______

Do you have any known health problems?______

______

Are you currently taking any medications or have you taken any medications for a prolonged period of time?______

______

Do you take any supplements, herbs or over the counter medications regularly?______

______

Do you currently have or have a history of any of the following: If yes, please circle

Diabetes Thyroid DisorderAnorexia/Bulimia Arrythmia/Palpitations

Hypertension InsomniaAsthmaOsteoporosis

DiarrheaConstipationIrritable BowelUlcerative Colitis

Crohn’s DiseaseAnxietyDepressionAdrenal Fatigue

AbuseAddictionIrritable BowelCeliac Disease

Food allergies AmenorrheaDysmenorrheaAnemia

SIBOMenopauseIrregular periodsFibromyalgia

Brain Fog Heart DiseaseAutoimmune DiseaseObesity

Gall Stones Kidney DiseaseDiverticulosisFlatulence

Frequent DiarrheaLaxative AbuseReflux/Heart BurnOral Contraceptives

AntibioticsReflux/Heart BurnUnexplained Weight Gain/Loss

Polycystic OvariesFaintingCompulsive Overeating Hypoglycemia

Use of Tobacco Use of Diet PillsCompulsive ExercisingCancer

Hirsutism Alcoholism /Abuse Frequent Bloating/Gas/Belching /Yeast Infections

Fatigue after MealsMood DisorderPhysical/Emotional/Sexual Abuse

Are you pregnant Y/N or breastfeeding? Y/N

Do you have any known food allergies /intolerances/sensitivities?______

How often do you have a bowel movement?______

Do you eat when you are: If yes, please circle

stressedanxiousalone

boredtired seeking comfort

watching tvon computerdepressed/sad

How often do you cook?______

How much time are you willing to spend preparing/cooking food daily?______

What foods/flavors do you crave?______

Do you consume caffeine? Y/N If yes, what and how much/ how often______

______

Do you consume alcohol? Y/N If yes, what and how much/how often______

______

Do you consume soda/pop/diet beverages/juice? If yes, how much and how often______

______

How many hours of sleep do you get per night?______

Do you feel well rested? Y/N

Do you eat fast food? Y/N If yes, how often?______

Do you exercise? Y/N If yes, what do you do and how frequently?______

______

If no, what prevents you from exercising?______

Do you have any injuries/physical limitations?______

When is the best/most convenient time for you to exercise?______

Any shortness of breath or pain in your chest or legs with exertion? Y/N

What is your stress level? Low/Moderate/High

What is your outlet for stress?______

Do you feel supported by friends/family? Y/N

What are your dietary goals?______

How will you feel if you achieve these goals?______

What obstacles are preventing you from achieving these goals?______

______

What motivates you?______

Please list below a typical day of eating, including beverages and snacks.