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 ______