Name Date of Birth. Address. Where did you grow up? . Phone. How do you prefer to be contacted?

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1 Date Name Date of Birth Address Where did you grow up? Phone How do you prefer to be contacted? Sign up for our e-newsletter (nutrition news, tips, events and recipes)? Age How old do you feel? Weight Height Marital status (single, in a relationship, married, divorced, widowed) Do you have children? If so, how old are they? Occupation Do you enjoy your job? Employer Employment Status: Full Time Part Time Retired (when?) Student Who is your physician? How did you hear about my services? Please list your main health concerns (in order of importance) What would you like to change or improve? Did something trigger the change in your health? What are your expectations for seeking nutritional therapy? HEALTH HISTORY 1

2 Please provide a brief history of your health. Include any previous surgeries and past or present illnesses, hospitalizations, or discomforts. Which health practitioners and doctors do you see? (List names, locations) Have you gained or lost a significant amount of weight in the past? When? How much? List the dietary and herbal supplements you take, with dosages: List the over-the-counter medications and prescriptions you take, with dosages: Do you have any allergies? If so, to what? How was your health as a child? List any conditions: Were you breast fed? Formula-fed? Delivered vaginally or by caesarean? What did your parents teach you about food? 2

3 DIGESTION AND ELIMINATION HEALTH & HISTORY How frequent are your bowel movements? # times for day or week COLON HEALTH Diarrhea Loose, unformed stool Constipation Hard, small stool Strain to eliminate Urgency to eliminate Alternating constipation and diarrhea Incomplete bowel emptying Recurrent colds and infections Laxative use Blood or mucus in stool Excessive gas Bloating Lower abdominal cramps Antibiotic use alleviated by passing gas or stool Toe or fingernail fungus HYPOACIDITY OF STOMACH Excessive burping Feeling overly full after meals Bloating Gas immediately after a meal Offensive breath Undigested foods in stool Protein feels like it sits in stomach Poor appetite Stomach is easily upset Known food allergies History of constipation Nausea after taking supplements Iron-deficiency anemia Foul smelling gas HYPERACIDITY OF STOMACH Stomach pain, burning 1-4 hrs after meals Stomach pain before meals Antacid or proton pump inhibitor use Hungry 1-2 hrs after meals Heartburn when lying down Relief from antacids, foods or drinks Digestive problems-subside with resting Heartburn from certain foods Burping Use of or NSAIDS (aspirin) Family history of ulcers or gastritis Current ulcer INTESTINAL PERMEABILITY Constipation Diarrhea Abdominal pain or bloating Joint pain or swelling, arthritis Frequent fatigue Food allergy, sensitivity, intolerance Sinus or nasal congestion Eczema or psoriasis Hives Skin rashes

4 Asthma Seasonal allergies or hay fever Poor memory Mood swings Use of NSAIDS (aspirin, Tylenol, ibuprophen) History of antibiotic use Alcohol makes you feel sick Ulcerative colitis, Crohn's, Celiac Headaches Migraines LIVE AND GALLBLADDER HEALTH Intolerance to fatty/greasy foods Headaches after eating Light colored stool Stools that float Less than 1 bowel movement daily Sour taste in mouth Fatigue after eating Gray-colored skin Yellow in whites of eyes Pain when passing stool Dry skin or hair Acne Triglyceride level above Total cholesterol above Bumps on back of arms PMS symptoms Keratosis HYPOFUNCTION OF SMALL INTESTINES AND OR PANCREAS Abdominal cramps Fatigue after eating Constipation from eating fiber Three or more large BMs daily Acne Food allergies Difficulty gaining weight Gallstones/Gallbladder disease Nausea Intolerance to probiotic suppl Restless leg syndrome Do certain foods tend to aggravate these issues? Which foods/ issues? Do you suspect you have food allergies or sensitivities? If so, to what? Past foreign travel? Where? When? Where? When? Where? When? When was the last time you were on antibiotics? What were they prescribed for? BLOOD SUGAR BALANCE 4

5 Crave sweets during the day Heart palpitations if skip meals Irritable if skipped meals Headache, lightheaded if skip meals Rely on coffee or soda in morning/afternoon Eating relieves fatigue Feel shaky, jittery or have tremors Agitated, easily upset, nervous Poor memory, forgetful Blurred vision Wake at night and can t fall back to sleep Have to eat in middle of night Fatigue after meals Sweet cravings not satisfied Crave sweets after meals Waist girth is larger than hip girth Frequent urination Increased thirst Always hungry Difficulty losing weight Excessively weak for no reason Get sleepy or tired after lunch NUTRIENT DEFICIENCIES Bruise easily Cannot recall dreams Numbness in hands or feet Muscle cramping while at rest/sleep Strong light irritates eyes Crave chocolate Anemia White spots on fingernails Reduced sense of taste/smell Susceptible to colds, infections MOUTH HEALTH & HISTORY Canker sores Cold sores Gum disease/infections Bleeding gums Root canals How many times per week do you floss? Have your wisdom teeth been taken out? Have any other teeth been extracted? HEAD / FACE HEALTH & HSTORY Post nasal drip Hair loss Dry eyes Watery eyes Dark circles under eyes Eye twitches Ear infections Night blindness Glaucoma Cataracts Vertigo CARDIOVASCULAR HEALTH & HISTORY 5

6 High blood pressure Low blood pressure Arrhythmias Palpitations Murmurs Edema Chest pain Atherosclerosis URINARY TRACT HEALTH & HISTORY Incontinence Pain with urination Kidney stones Urinary tract infections Discharge/blood in urine Urgency Foul smelling urine Dark colored urine NERVOUS SYSTEM & HISTORY Carpal tunnel Seizures Tingling or numbness Fainting ADRENAL FUNCTION Cannot stay asleep Cannot fall asleep Slow starter in the morning Afternoon fatigue Dizzy when standing quickly Afternoon headaches Weak or ridged fingernails Low blood pressure Slow recovery from colds Poor circulation Susceptible to respiratory infections Difficulty holding chiropractic adj Cravings for salt Perspire easily Under a lot of stress and often Weight gain when stressed Wake tired after 6+ hrs of sleep Hot flashes Low sex drive Nervous/anxious Ankle, foot or low back pain Cry easily THYROID FUNCTION Tires, sluggish, fatigue Cold hands, feet, body Trouble waking in morning Weight gain even with low cal diet Difficulty losing weight Constipation, infrequent BMs Depression, lack of motivation Morning headache that wears off Thinning hair on outer eyebrow Hair loss or thinning on scalp Dry skin and scalp Mental sluggishness Ringing in ears or noises in head Nervous, emotional, anxious Fast pulse even at rest Night sweats

7 Insomnia Intolerant of high temperatures Difficulty gaining weight FEMALE REPRODUCTION HEALTH & HISTORY Describe your menstrual cycle: Light/ or heavy How many days Cramping Clotting PMS What do you use to relieve these symptoms? Does it help? Are you sexually active? If so, what method of birth control do you use? List types of birth control used in the past: Used for how long? How many times pregnant? How many children? Miscarriages? Type of delivery: vaginal caesarean Menopausal? Since what age? Use of replacement hormones? Pain with intercourse Vaginitis/abnormal discharge Abnormal pap smear Abnormal mammogram Endometriosis PCOS Breast cysts Fibroids MALE REPRODUCTION HEALTH & HISTORY Hernia Prostate inflammation/bph Erectile dysfunction Difficulty urinating EMOTIONAL HEALTH & HISTORY Depression Anger Anxiety, panic attacks Irritability Memory Loss Brain fog Difficulty concentrating Hyperactivity Impulsiveness Feel overwhelmed FAMILY HEALTH HISTORY 7

8 Has anyone in your family (including parents, grandparents, siblings, and children) experienced any of the following illnesses/ conditions? Condition Which family member Condition Which family member? Heart Disease Thyroid High blood pressure Autoimmune issues Heart attack Arthritis Stroke Osteoporosis High cholesterol Alzheimer's Diabetes Dementia Asthma Mental illness Cancer Alcoholism Depression Drug addiction Food allergies Eating disorders DIET AND EATING HABITS How many meals per day do you eat? Do you follow any specific food guidelines (ie: vegan, vegetarian, gluten-free, Paleo, etc.)? 3 Day Diet Journal (please include everything that goes in your mouth, give approximate amounts and brands/restaurants) Breakfast Lunch Dinner Snack/beverages Day 1 Day 2 Day 3 What are some of your favorite foods? 8

9 What are some of your least favorite foods? Which foods do you crave? Do you crave sweets? How often? When? Do you consider yourself a fast or slow eater? What do you drink during the day? How many glasses (or ounces) of water each day? How much alcohol do you consume during an average week? (# of beers/ glasses of wine or cocktails) Do you drink coffee? How many cups per day? Do you drink soda? How many per day/ per week? How often do you cook at home? Do you like to cook? How often do you eat at restaurants or take-out per week? Which places do you frequent? How often do you grocery shop? Once a week Twice a week More frequently Where do you usually eat? (ex: at table, in front of TV, at desk at work ) What is your idea of a healthy meal? What does an unhealthy meal, one that doesn t make you feel good, look like? POTENTIAL TOXIN EXPOSURE Have you been exposed to any toxins that you re aware of? Have you ever lived near a manufacturing plant, farm or industrial area? Have you ever worked on a farm or in a manufacturing plant? Do you have (or did you have) mercury (silver) fillings in your teeth? Did you grow up in a house built before 1976 that may have had lead paint? Do you use solvents or paints in your work or hobbies? Does your home have new carpet, new paint or new furniture? Do you sleep on a new mattress? Do you live in a brand new home? What year was it built? Do you have a strong reaction to smells? Are you very sensitive to medications and/ or caffeine? Do you use pesticides, herbicides or cleaning chemicals in your house? Do you travel often or have you worked in the airline industry? Do you swim in a chlorinated pool often? Do you drink well, tap, filtered or spring/ bottled water? Did you receive all scheduled vaccinations as a child? Have you recently received any vaccinations (for international travel or flu shot, etc.)? 9

10 Do you use nicotine? If so, what type? Have you used nicotine in the past? What type? For how long? Are you often exposed to second hand smoke? Do you use any recreational drugs? What types? How often? Did you have a habit of using drugs in the past? If so, which ones? LIFESTYLE & MOVEMENT What is your stress level from 1 10 (1 being the lowest, 10 being the highest) List your stressors: How do you manage it? Have you experienced a major stress in the past, such as divorce, loss of a loved one or pet, care taking an ill family member or friend, difficult relationship, etc.? How many hours per night do you sleep? Do you wake up feeling refreshed? Do you fall asleep easily? Do you wake up in the night? Do you frequently have insomnia? How many nights per week? Are you tired throughout the day? When? How often do you exercise per week? For how many minutes? What type(s) of exercise? Do you enjoy exercising? Do you feel like you re in good shape? What are your hobbies and past times? Are you happy with your life? If not, what would you change? What challenges do you face in order to create that happiness? On a scale of 1 10 (10 being the highest) how committed are you to your goals? On a scale of 1 10 (10 being the highest) how willing are you to change your diet and eating habits? What else would you like to share? 10