Nutritional Health Questionnaire
Lisa Blake, CNC (760) 729-7212
Name______Date of Birth___/___/___ Age ___Date______
Address______Zip______
Home phone(___)_____-______Cell(___)_____-______email______
Are you CURRENTLY being treated for a medical condition? Please List
- ______2.______3.______
4. ______5. ______6.______
Please list PAST surgeries or medical conditions
1.______date ___/___/____ 2.______date___/___/____
3.______date ___/___/____ 4.______date___/___/____
Notes______
Are you currently on a special (vegetarian, low-fat, gluten free) diet? ______
Are you taking any medications & for what condition?______
______If more than 3 medications are taken, Please bring a list on your appointment day.
List any family history of diabetes, high blood pressure, or high cholesterol?______
______
Do you have indigestion? ____yes ___noGas?____yes ___noBloating?____yes ___no
What foods tend to cause you indigestion, bloating or gas?______
Do you have diarrhea? ___yes ___noConstipation?___yes ___no Both? ___yes ___no
Do you have or have you had any of the following? CIRCLE and explain BRIEFLY on the lines provided at the bottom of this sheet.
ACNE
HEADACHES
ALCHOLISM
ALLERGIES
RESPITORY PROBLEMS
SKIN PROBLEMS
SINUSITIS
HEART DISEASE
HIV/AIDS
ARTHRITIS
NERVOUS DISORDER
SEXUAL DISORDER
ASTHMA
CANCER
DIGESTIVE DISORDER
DEPRESSION
DIABETES
TUMORS
Page 2
List current vitamins or supplements? ______
______
Briefly describe a typical work day.______
How active are you? not active ____ a little active ____ moderately active ____ very active ___
How often do you exercise? ______times per week What type of exercise?______
Height______Weight______What would be your ideal weight ______
Describe changes, if any, that you have made to your eating and/or exercise habits______
______
Last menstrual period ___/____/____ Mood Swings? ___yes ___No Night Sweats/Hot Flashes? ___Yes __No
Do you drink alcoholic beverages? ______per week Cups of coffee per day? ______Cups of tea per day?___
Do you like to cook? ___yes ___no Are you interested in healthy cooking classes? ___yes ___no
Do you eat a lot of processed foods? ____yes ____no Do you like to food shop? ___yes ___no
Do you drink/eat meal replacements shakes and bars? __yes __no
Do you eat animal products?____ Dairy products?_____ Desserts or sweets regularly?______
What do you eat for a typical breakfast?______
Typical lunch?______
Dinner? ______
Does your food or weight feel out of control? ___yes ___no
Your favorite restaurant? ______Favorite fast food restaurant?______
Do you smoke? ____yes ____no How many glasses of water do you drink each day? ______
List any food allergies ______
Have you been tested for food sensitivities? __yes __no What foods are you sensitive too?______
______
Pieces of fruit eaten per day?_____ Vegetables per day? ____ Do you Crave Carbs? ___yes ___no
How often do you eat out? _____ times per week. Do you snack between meals? ___yes ___no
Do you use artificial sweeteners? _____ Do you drink Soda? ______How many per week?______
Page 3
Do you work?___full time ___part time Occupation______
Do you enjoy the work that you do? ___ yes ___ no If not, explain______
______
How many children do you have?____ Ages:______
Recreational activities you enjoy______
Circle the following categories, which cause youstress
Financial~job related ~ getting along with people ~ family spouse/children ~ not happy with myself
On a scale of 1 to 10 rate stress level ( 1 = very little stress and 10 = an extreme amount of stress)_____
The following space is for those who would like to elaborate more on the causes of their stress, depression, or other negative emotions. ______
______
What do you do when you are stressed? ______
ROPERREST
What time do you go to bed? _____What time do you awake?_____Trouble sleeping?___yes __no
Explain:______
Realistically list what specific condition(s) would you like your consultation to address?
______
______
Explain why you would like to receive Nutrition counseling at this time______
______
What are your long-term goals? 1.______2.______
Please indicate that you understand that this questionnaire and the educational information provided in this consultation is not intended to diagnose or to treat any disease, ailments or abnormality, and that it serves merely as background information in order for me to ADVISE you on a healthier lifestyle according to your condition.
I understand and have read the disclaimer _____YES _____NO
The QuestionnaireS
Signature______Print Name ______Date ______