Lifestyle and Nutritional Assessment Form

Lifestyle and Nutritional Assessment Form

Dear Client: Please read the instructions of each form carefully and complete this questionnaire with care. Your answers will help me determine the most effective recommendations to make based on your main health concern(s) presented. This health history record is protected and kept strictly confidential. It will not be released without your consent.

Name:

Date:

Telephone (Home):

(Work):

(Cell):

Email:

Age:

Sex: M F

Height:

Weight:

Appointment Reminders? No Email Phone AHS Quarterly Newsletters? Yes No

Please answer each question carefully and LEAVE BLANK those that don’t apply to you.

LIFESTYLE:

What is your #1 goal you want to achieve during our time together?

What are your main health concerns?Please list concerns in priorityand when they started:

1. / 4.
2. / 5.
3. / 6.

Have you ever experienced any major trauma?

What level of stress do you currently experience?Please quantify on a scale of 1 (low) to 10 (high):

What are the major causes of your stress?

How does your stress manifest (show)?

What coping mechanisms do you implement?

Do you vacation regularly? Yes No What was your last vacation?

What is your current exercise routine? (Include type, frequency and duration)

Are you satisfied with your present weight? Yes No

Do you wish to gain weight? lose weight? If so, how much?

How would you describe your energy levels on a scale of 1 (low) to 10 (high)?

Do you experience any lulls or highs in energy levels throughout the day? Yes No

If so, what time(s) of day?

How many hours on average do you sleep daily?

Do you: have difficulty falling asleep? Staying asleep? Awaken feeling unrested? Snore?

What is your occupation?

What do you enjoy/not enjoy about work?

How many hours each week do you work?

Do you work shifts? Regular schedule?

Do you smoke? Yes No If yes, how much and for how long?

How do you feel about smoking?

Are you ever exposed to smoke at home or at work? Yes No

Do you use recreational drugs? Yes No If yes, please describe:

Have you ever been treated for: drug dependency? Alcohol dependency?

How many hours do you spend daily, on average:

Driving?

Watching TV?

Reading?

Ona computer?

Sitting at a desk?

What isyour currentmorning routine?

Evening routine?

What are your interests and hobbies? Please list:

How much free time do you feel you have in a day?

If need be, how would you make more time for yourself?

Do you regularly check in with yourself (self-reflect)? Yes No Need reminders to do so

Time permitting, what would you like to incorporate into your day?

MEDICAL HISTORY:

Are you currently taking medication (including birth control)? Yes No

Name of Prescription Medication / Reason(s) for Medication / Duration of Medication

Have you taken antibiotics over the past 5 years? Yes No

If yes, when werethey last taken and the reason for taking it?

Are you currently taking Natural Health Products (NHPs)? (Includes vitamins, minerals, herbs and homeopathic remedies) Yes No

Name of NHP / Reason(s) for NHP / Daily Amount/Dose

Do you have any allergies or sensitivities (includingto medication)? Yes No

If so, please list:

Are youanaphylactic (life-threatening allergy)? If so, to what:

Do you have any silver-mercury fillings? Yes No

If so, how many and for how long?

Do you have any root canals? Yes No If so, how many and for how long?

Have you ever been:

a) Diagnosed with an illness? Yes No If so, please explain:

b) Hospitalized? Yes No If so, for what reason:

Have you had surgery to remove your gall bladder? Tonsils? Appendix?

If so, explain:

Have you experienced fungal infections (Ex. Jock itch, Athlete’s foot)? Yes No

If so, please describe:

Have you experienced a decline in sexual interest? Yes No

Have you had kidney stones or gallstones? Yes No If yes, please describe:

How often do you have a bowel movement daily?

Do you strain to have a bowel movement? Yes No Occasionally

Related to particular food or circumstance?

Do you have loose bowel movements? Yes No Occasionally

Related to particular food or circumstance?

Is there undigested food in your stools? Yes No Occasionally

Other bowel-related concerns? (Colour, blood, oily, etc.)

FAMILY HISTORY:Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for other(s):

Allergies / Diabetes / Intestinal Disease
Alcoholism / Drug Abuse / Kidney Dysfunction
Arthritis / Gall Bladder Issues / Mental Illness
Asthma / High Cholesterol / Osteoporosis
Autoimmune Disease / Heart Disease / Skin Conditions
Cancer / Hypertension / Ulcers
Type(s) of Cancer: / Other condition(s):

FEMALES:

Are you pregnant? Yes No Are you currently breastfeeding? Yes No

Have you noticedany changes in menses? (Ex. Frequency, duration, flow, clotting, etc.) Yes No

If so, please specify:

Do you suffer from PMS symptoms? Please specify:

Are you pre-menopausal? Yes No Post-menopausal? Yes No

Are you experiencing any menopausal symptoms? Yes No

If yes, please specify:

Have you had a bone density test? Yes No If yes, what was the result?

MALES:

Have you experienced any prostate problems? (Ex. frequent urination, discomfort during urination)

Yes No If yes, please describe:

NUTRITIONAL AND DIETARY HABITS:

How many times a day do you eat, on average?

Main meals: Times of day:

Snacks: Times of day:

Provide examples of your typical meals and snacks:

Breakfast:

Lunch:

Dinner:

Snacks:

Do you eat: With family? Home alone? On the run? Restaurant? Fast food?

Where do you commonly grocery shop?

What percentage of meals/snacks consumed are homemade?

In terms of preparing your own meals, what is your skill level in the kitchen? Please quantify on a scale of 1 (low) to 10 (high):

How many servings of each food type do you typically consumein a day?

FruitFresh Frozen Canned Dried

VegetablesCooked Raw Frozen Canned

Whole GrainsType:

ProteinType:

DairyType:

FatsType:

OtherType(s):

Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”):

Aluminum pans

Artificial Sweeteners

Candy

Cigarettes

Refined Foods (pastries, white pasta, etc.)

Fried Foods

Luncheon Meats

Margarine

Microwave

Fast Foods

Please indicate how many cups of the following you drink per day:

Tap water

Coffee

Tea

Soft drinks (diet)

Soft drinks (regular)

Fresh fruit juices

Fruit juices (prepared)

Milk

Prepared vegetable juices

Fresh vegetable juices

Red wine

White wine

Beer

Other alcoholic beverages

Bottled or spring water

Herbal tea

Other:

Do you currently follow a special diet? Yes No If yes, please explain:

Do you avoid certain foods? Yes No If yes, list food(s) and reason why:

How often do you eat meat?Daily 3-5/week Once/week or less

How often do you consume dairy?Daily 3-5/week Once/week or less

What’s your favourite food(s) and how often do you eat them?

Which food(s) do you crave, and how often do you eat them?

Do you experience any symptoms of meals are missed? Yes No

Please explain:

Do you experience any symptoms after meals? Yes No

Please explain:

COMMENTS:

Nutri-System Profile (NSP) Assessment Form

Please indicate if you’re experiencing any of the symptoms or activities below by indicating:1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

General fatigue or weakness / Varicose veins
Difficulty losing weight / Feeling out of control
Frequent illness/infections / Food/chemical sensitivities
High stress lifestyle / Frequent yeast/fungus problems
Smoking / Bones break easily, osteoporosis
Drink more than 2 cups of coffee/day / Too little exercise
Bad breathe and/or body odour / Excessive mucous
Constipation / Shortness of breath climbing stairs
Bags under eyes / Tingling in lips, fingers, arms, legs
Craves sugar, bread, alcohol / Chest pains
Difficulty digesting certain foods / Very rapid or slow heart beat
Recent antibiotic use / Painful, hard or thin bowel movements
Allergies / Alternating constipation/diarrhea
Poor concentration or memory / Recurrent bladder infections
Belching or burping after meals / Female: Menopause, hot flashes
Skin/complexion problems / Female: PMS
Frequent consumption of red meat / Difficult urination
Regular use of dairy products / Swollen glands, puffy throat
Heavy alcohol consumption / Lower abdominal pain
Exposure to toxins/chemicals / Frequent need to urinate
Frequent mood swings / Joint pain
Depressed and/or irritable / Sinus inflammation/discharge
Brittle fingernails / Arthritis
Dry, brittle hair, split ends / Sudden weight gain/loss
High fat/high cholesterol diet / Headache/Migraines
Nervousness/anxiety/tension/worry / Female: Taking birth control pills
Insomnia, restless sleep / Lower back pains
Low fiber diet / Dry, flaky skin
Muscle cramps / Drink less than 6 glasses of fluid/day
Sleepy when sitting up / Water retention
Female: menstrual cramps / Low sex drive
Bronchitis/asthma//pneumonia/emphysema / Feeling heavy/bloated after meals
Cellulite / Chronic cough
Cold hands and feet

COMMENTS:

PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM:1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.

THE DIGESTIVE SYSTEM

Excessive gas, belching or burping after meals / Full feeling after heavy meat meal
Stomach bloated after eating / Heavy, tired feeling after eating
Sleepy after eating / Nausea after taking supplements
Longitudinal striations on fingernails / Acne
Eat when rushed/in a hurry / Undigested food in the stool
Bad breathe
Stomach pain 1 hour after eating or at night / Sensation of acidity in abdominal area
Burning sensation in stomach / Heartburn, indigestion
Pain aggravated by worry/tension / Blood in stool
Hiatal hernia / Lower back pain
Gastritis, gastric ulcer / Long term aspirin use
Nausea, vomiting
Yellow or pale fingernails / Food allergies
Skin oily on nose and forehead / Irritable, easily angered
Fats/greasy foods cause nausea, headaches / Weight gain around the abdomen
Vertical white streaks on fingernails / Yellow palms
Onions, cabbage, radishes, cucumbers cause bloating/gas / Jaundice
Bad breathe; bad taste in mouth / Poor concentration
Excess body odour / Difficulty losing weight
High cholesterol/high cholesterol diet / Acne, boils, rashes, psoriasis or eczema
Migraine headaches / Constipation
Discomfort underneath right ribcage
Gall stones; history of gallstones / High cholesterol diet; high blood cholesterol levels
Stool appears clay-coloured, foul odoured / Severe pain in right upper abdomen
Constipation
Severe abdominal pain / Fever
Nausea and vomiting / Alcohol addiction
Slow digestion; feel full for hours after eating / Jaundice
Hungry up to 3 hours after eating / Family history of diabetes
Strong cravings for sweets, starches, coffee or alcohol / Fatigue
Nervous/anxious feelings relieved by eating / Frequent headaches
Irritable if late for or skip a meal / Fainting spells
Overweight / Depression
Addicted to pop and/or coffee with sugar / Lose temper easily
Frequent “midnight snacks”

THE INTESTINAL SYSTEM

Extreme fatigue / Rectal itching
Recurrent vaginal infections / Abnormal muscle aches from exercise
Frequent use of antibiotics / Excessive wax in ears
White coated tongue, oral thrush / Unexpected/unexplained weight gain
Craves sugars, bread, alcohol / Impotence
Headaches / Canker sores
Tonsillitis, recurrent strep throat / Athlete’s foot, finger/toenail fungus, ringworm
Itchy, watery or dry eyes / Jock itch
Skin flushes / “Brain fog”
Chronic indigestion, frequently use antacids / Irritability
Always cold, especially in extremities / Memory loss
Female: PMS / Mental confusion
Pain in pelvic area / Depression or anger for no reason
Abdominal gas and bloating / Anxiety/panic attacks
Loss of sex drive / Inability to concentrate
Cystitis, repeated bladder infection / Phobic/compulsive
Increasing food and chemical sensitivities / Lethargy
Female: Endometriosis/ ovary problems / Mood swings
Chronic diarrhea / Itchy ears, nose, anus
Hives, psoriasis, acne, skin rashes
Forgetfulness / Pain in the back, thighs, shoulders
Slow reflexes / Numb hands
Gas and bloating / Drooling while sleeping
Unclear thinking / Damp lips at night
Loss of appetite / Dry lips during the day
Yellowish or pale face / Grind teeth while asleep
Fast heartbeat / Bedwetting
Heart pin / Lethargy; chronic fatigue
Pain in navel / Dark circles under eyes
Eating more than normal but still feeling hungry / Cancer
Blurry or unclear vision / Rectal itching

THE LYMPHATIC SYSTEM

Excessive sleep / Soreness on both sides of neck at shoulder
Very susceptible to infections / Feel puffiness in throat
Swollen glands: tonsils, throat, armpits / Look older than chronological age
History of cancer, MS, Parkinson’s, arthritis / Flu-like symptoms often occur
Loss of appetite / Lupus
Headaches

Acne, psoriasis, dermatitis, eczema / Excessive sweating, night sweats
Rapid pulse, heart irregularities / Bowel disease: IBS, IBD, Crohn’s, etc.
Frequent headaches / Joint pains or stiffness
Hay fever / Frequent night urination
Frequent cravings for certain foods / Wheezing
Periods of blurred vision / Pale face
Repeated ear trouble / Hives
Hyperactivity / Nose runs constantly
Dizzy spells / Noticeable changes in writing throughout day
Periods of confusion / Nosebleeds
Poor concentration / Bloating or gas after eating certain foods
Epilepsy / Canker sores
Muscle cramps or spasms / Dark circles under eyes
Abnormal body odour / Stuffy nose

THE ENDOCRINE SYSTEM

Distinct, lethargic tiredness or sluggishness / Hair dry, brittle, dull, lifeless
Cold hands or feet / Flaky, dry rough skin
Mercury amalgams (fillings) / Feel stiff after sitting still for some time
Gain weight easily, fail to lose on diets / Mood swings
Constipation, less than one bowel movement a day / Usually square and wide fingernails
Low energy in the morning / High cholesterol
Low pulse rate / Low sex drive
Low body temperature, especially bed rest
Losing weight without trying / Insomnia
Heart races while at rest / Increased appetite
Feel warm/flushed at room temperature / Frequent bowel movements, diarrhea
Hands shake or tremble / Excessive sweating without exercising
Protruding tongue / Nervous behavior, hyperactivity
Heart palpitations
Headaches affecting one side of head / Excessive urination
Female: Loss of menstrual function / Pain in little finger of left hand
Moody / Swelling in ankles, fingers and/or feet
Overweight from waist up / Cold hands or feet
Overweight from waist down / Pain in left side of upper neck
Stress or emotional upset cause exhaustion / Occasional cold sweats
Dizzy/light-headed upon standing quickly from a lying or crouched position / Tightness or lump in throat, especially when emotionally disturbed
Sweat excessively / High or low blood pressure
Neck and/or shoulder tension/pain / Rapid pulse
Frequent headaches / Short temper
Bow lines (depressed furrows) on fingernails / Puffy face

Forgetfulness, “brain fog” / Low resistance to infections, catch cold/flu easily
Energy crash mid-afternoon (around 2-5pm) / Difficulty falling or staying asleep
Need to snack to help energy levels and cravings / Increased muscle soreness with similar physical activity level
Abdominal weight gain / Female: Worsened PMS symptoms during menstrual cycle
Low sex drive or lack of interest / Frequently wake up around 2-4pm, can’t fall back asleep
Anxiety, irritability, depression (mood swings) / Low stamina, energy and difficulty maintaining muscle mass
Decreased ability to deal with stress and deadlines / Low tolerance towards alcohol or caffeine
Strong carbohydrate or salt cravings / Cold hands or feet/other extremities
Hair loss / Dry skin
Significant improvements in stress levels during vacation or time away from work?

THE STRUCTURAL-MUSCULAR/SKELETAL SYSTEM

Pain, swelling, stiffness in joints / Rounding of shoulders, stooping
Joint inflammation (rheumatoid arthritis) / Female: Menopause
Pain, stiffness, inflammation of spine / Pain in forearm or biceps
Facial pain / Cramps in calf muscle during sleep or exercise
Joints making popping sounds / Painful cramping in feet or toes
Gout / Teeth prone to decay; frequent toothaches
Ankylosing spondylitis / Malformation of bones
Bones fracture easily / Insomnia
Gradual loss of height / Muscles weak, weak grip, light objects feel heavy
Tooth loss; teeth “falling out” / Heart palpitations
Lack of exercise / Diet high in animal foods (meat, dairy, eggs)
Muscle pain / Sprains; muscle strains
Muscle weakness / Muscle(s) spasm
Muscle wasting in some part of the body / Tremors
Numbness or loss of sensation / Loss of peripheral vision
Mood swings and/or depression / Slurred speech
Blurred or double vision / Objects fall from hand, reach in wrong place
Tingling and/or numbness, especially in extremities / Hands tremble
Muscular stiffness / Impaired speech
Male: Impotence / Difficulty breathing

COMMENTS: