Client ID

Health History and Lifestyle

What is your main reason for seeking nutritional consulting? Please describe in detail.

Please list any other health concerns (physical, emotional, or mental) in order of importance.

Please list any health conditions (current or anything from past you feel is relevant).

Indicate whether you have had blood relatives with any of the following problems:
 Cancer Diabetes Heart Disease High Cholesterol High Blood Pressure Osteoporosis Thyroid Disorder Allergies Celiac Disease Crohn's Disease Other Autoimmune Disease Mental Illness

How would you rate your overall health?:
 Poor Fair Average Good Excellent

Do you have complaints about any of the following?
 Loss of Appetite Problems with Chewing or Swallowing Nausea Indigestion (general) Constipation Diarrhea/Loose Stools Abdominal Bloating Belching Flatulence Acid Reflux/Heartburn Lower abdominal cramping Sudden Weight Change Fatigue Dizziness Headache Hives/allergic reactions Acne/skin eruptions Itchy skin Bruising Easily Skin Dryness Skin redness/inflammation Frequent Urination Joint/Muscle Pain Muscle Weakness Low Blood Pressure High Blood Pressure Jaundice Liver issues Gallbladder issues Insomnia/Sleep Issues Problems seeing in dim light Edema (swelling) Menstrual Difficulties

What is your current weight and height? What have your weight patterns =
been like throughout your life?

Do you use tobacco in any way? If so, how much?

Did you recently stop smoking?

Do you enjoy physical activity? Please explain.

List any food allergies or intolerances.

Drug History

List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take. Be as specific as possible with dosage and how often you take them.

List any drug allergies.

Diet History

Do you follow a special dietary plan, such as low cholesterol, kosher, or vegetarian?

Have you ever followed a special diet? If so please explain.

Do you have any problems purchasing foods that you want to buy?

Are there certain foods that you do not eat?

How much water do you drink in a day?

Do you eat at regular times each day? How often?

Identify any foods you particularly like.

Do you drink alcohol? If so, how often?

What change would you like to make?
 Improve my eating habits Learn to manage my weight Improve my activity level Improve my cholesterol/triglyceride levels
Other (please explain):

Please add any additional information you feel may be relevant to understanding your nutritional health

To tailor your counseling experience to your needs, it would be useful to know your expectations. Please check one of the following to indicate the amount of structure you believe meets your needs:
 Just tell me exactly what to eat for all my meals and snacks. I want a detailed food plan. (Example: 3/4 cup corn flakes, 1 cup skim milk, 6 oz. orange juice.) I want a lot of structure but freedom to select foods. I want to use the exchange system. (Example: 1 milk, 2 starch, 1 fruit, 1 fat exchange.) I want some structure and freedom to select foods. I want to use a food group plan. (Example: 1 serving of dairy foods, fruits, and fat and oil group; 2 servings of grains.) I don't want a diet. I just want to eat better. I will just set food goals each week.

Please enter the characters you see in the image above.