NEW CLIENT QUESTIONNAIRE

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Robert Austin
5 years ago
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1 PAGE 1 NEW CLIENT QUESTIONNAIRE FULL NAME: AGE: DATE OF BIRTH: HEIGHT: GENDER: ADDRESS: PHONE (H:) (C:) BEST CONTACT? CURRENT WEIGHT : 6-MONTHS AGO? 1-YEAR AGO? ARE YOU LOOKING TO: LOSE GAIN MAINTAIN HOW MUCH? TIME FRAME? CLIENT BACKGROUND PLEASE LIST YOUR MAIN HEALTH CONCERNS/SYMPTOMS: HOW LONG HAVE YOU EXPERIENCED THESE? ARE THERE ANY FACTORS THAT MAY HAVE/CONTINUE TO PERPETUATE THIS CONDITION? HAVE YOU CONSULTED ANY OF THE FOLLOWING FOR THIS? YES / NO MEDICAL DOCTOR NATUROPATH DIETICIAN OTHER PLEASE DESCRIBE THEIR TREATMENT PROTOCOL: HAVE YOU USED/TRIED ANY OF THE FOLLOWING TREATMENTS? DIET MODIFICATION VITES/SUPPS HOMEOPATHY/TCM CHIROPRACTOR ACUPUNCTURE Rx DRUGS NATUROPATHY ACUPUNCTURE HEALTH HISTORY: CURRENT RELATIONSHIP STATUS: NAME OF SPOUSE: CHILDREN? AGES? OCCUPATION: SHIFT WORK? DO YOU ENJOY WORK? LEVEL OF HOME (1=LOW-10= WORK MAJOR CAUSES OF STRESS:

2 PAGE 2 HOURS PER DAY SPENT: WORKING: TRAVELING: SITTING: COMPUTER/TV: HOW WOULD YOU RATE YOUR HEALTH? EXCELLENT GOOD FAIR POOR PLEASE LIST ALL KNOWN FOOD ALLERGIES & SENSITIVITIES ALLERGY/SENSITIVITY SYMPTOMS TREATMENT? PLEASE LIST ALL PERTINENT/CURRENT SUPPLEMENTS & PRESCRIPTIONS: NAME DOSE LENGTH OF USE PRESCRIBED? CURRENT? HAVE YOU RECENTLY TAKEN ANTIBIOTICS? LENGTH OF USE? WHAT IS YOUR BLOOD TYPE? A B AB O HOW IS/WAS THE HEALTH OF YOUR PARENTS? FAMILY HISTORY OF PARTICULAR DISEASE/SYMPTOM? : GENERAL ENERGY (1= Low 10= High) HIGHEST? LOWEST? DO YOU SUFFER FROM ANY OF THE FOLLOWING? SEASONAL ALLERGIES CONSTIPATION GALL/KIDNEY STONES ANXIETY DRY FLAKY SKIN GOUT LOW LIBIDO BAD BREATH/ODOR DIARRHEA HEADACHES POOR MEMORY BLOATING/PUFFINESS DIFFICULT URINATION IRRITABILITY WEIGHT LOSS COLD HANDS/FEET FREQ. URINATION JOINT PAIN WEIGHT GAIN HOW MANY TIMES PER DAY DO YOU: SMOKE: DRINK ALCOHOL: DRINK COFFEE: HOW OFTEN DO YOU EXERCISE? 1-2 DAYS PER WEEK 3-4 DPW 5-7 DPW DURATION & INTENSITY/TYPE OF WORKOUT: HOURS OF SLEEP? DIFFICULTY FALLING ASLEEP? STAYING ASLEEP? WHAT TIME DO YOU WAKE? GO TO SLEEP?

3 PAGE 3 HAVE YOU SUFFERED/BEEN DIAGNOSED FROM ANY OF THE FOLLOWING? ALCOHOLISM CANCER DIABETES I FIBROMYALGIA HYPO- ALZHEIMERS HEART DISEASE DIABETES II HEP A THYROID ANEMIA CELIACS DIGESTIVE ISSUES HEP B MIGRAINES ASTHMA FATIGUE EMO. EATING HEP C NEURODE- AUTO-IMMUNE COLITIS ECZEMA HIGH BP GENERATIVE BRONCHITIS DEPRESSION EPILEPSY HIGH CHOL. BILIARY DISEASE DEMENTIA EBV HYPER-THYROID DIET & NUTRITION: APPROXIMATE GLASSES/OUNCES WATER PER DAY? IS IT FILTERED? DO YOU CATEGORIZE YOURSELF AS FOLLOWING A DIET: LOW CARB LOW FAT GLUTEN FREE HIGH CARB HIGH PROTEIN PALEO PESCATARIAN RAW VEGETARIAN VEGAN OTHER? RATE THE FREQUENCY YOU USE THE FOLLOWING (1 = LOW 10= HIGH) ARTIFICIAL SWEETENERS SALTY JUNK FOOD PROTEIN BARS/SHAKES BEANS/LEGUMES MILK ALTERNATIVES REFINED FLOURS DAIRY/CHEESE NON-STARCHY VEG. SWEET SNACKS FRUIT NUTS/SEEDS STARCHY VEG. LEAFY GREENS PROCESSED DELI MEATS WHOLE GRAINS WHAT TIME DO YOU EAT: BREAKFAST LUNCH: DINNER: SNACK(S:) DO YOU PRIMARILY PREPARE or PURCHASE YOUR SNACKS/MEALS? _ HOW WOULD YOU RATE YOUR CULINARY KNOWLEDGE/ EXPERIENCE? (1=NOVICE 10= PRO) WHAT ARE WOULD YOU SAY ARE YOUR BIGGEST INHIBITORS FOR EATING HEALTHIER? MOST OF YOUR MEALS TAKE PLACE: RESTAURANT HOME ALONE FAST FOOD CAR/ON THE GO STANDING FAMILY

4 PAGE 4 TYPICAL DAY OF MEALS: BREAKFAST: LUNCH: DINNER: SNACKS: WHAT ARE YOUR FAVORITE RESTAURANTs or CUISINES? AMERICAN/ BURGERS DINER/COMFORT JAPANESE/ SUSHI SOUL FOOD BBQ FRENCH MEXICAN SPANISH CHINESE HEALTHY/ORGANIC MEDITERRANEAN PUB DELI ITALIAN MIDDLE EASTERN VEGAN PLEASE LIST 2-3 RESTAURANTS WHERE YOU DINE OFTEN: _ LIST 2-3 OF YOUR FAVORITE DISHES TO ORDER OUT: LIST 2-3 OF YOUR FAVORITE DISHES TO MAKE AT HOME: FOOD SENSITIVITIES/AVERSIONS/AVOIDANCE? _ WHAT FOODS ARE YOU NOT WILLING TO GIVE UP? DO YOU CRAVE FOODS THAT ARE HIGH IN: CHOCOLATE CARBS FAT PROTEIN SALT SUGAR DO YOU SUFFER FROM ANY OF ThE FOLLOWING FOOD SENSITIVITIES? EGGS FISH ONIONS PEPPERS TOMATOES EGGPLANT GARLIC MUSHROOMS SHELLFISH TREE NUTS DAIRY GLUTEN PEANUTS SOY WHEAT OTHER: PLEASE CHECK THOSE YOU CONSUME: : BISON FISH PORK SHELLFISH VEAL CHICKEN GOAT/LAMB RED MEAT TURKEY VEGAN PLEASE LIST YOUR FAVORITE TYPES OF FISH/SHELL- FISH:

5 PAGE 5 DO YOU EAT ANY OF THE FOLLOWING DAIRY PRODUCTS EACH WEEK? EGG WHITES GOAT CHEESE MILK ALT. PECORINO EGG YOLKS GREEK YOGURT 2% MILK FETA CHEESE KEFIR PARMESAN PLEASE LIST THE FOLLOWING: Other Cheeses? FAVORITE PASTA SAUCE (s:) FAVORITE SOUP (S:) FAVORITE SALAD DRESSING (S:) PLEASE CHECK ALL VEGETABLES YOU ENJOY EATING: ARTICHOKES BRUSSEL SPROUTS CORN FENNEL PEAS ASPARAGUS CABBAGE CUCUMBER KALE PEPPER ARUGULA CAULIFLOWER DANDELION MUSHROOM POTATO BEETS CARROTS EGGPLANT NORI SQUASH BROCCOLI CELERY ESCAROLE PALM HEART SPINACH ZUCCHINI PLEASE CHECK ALL FRUITS YOU ENJOY EATING: APPLES BLACKBERRIES PEACHES GRAPES NECTARINES APRICOTS BLUEBERRIES PLUMS KIWI ORANGES AVOCADO CANTALOUPE FIGS LYCHEE OLIVES BANANA CHERRIES GRAPEFRUIT MANGO PEARS WATERMLN CLEMENTINES PLEASE CHECK ALL HERBS/SPICES YOU ENJOY EATING: ALLSPICE CILANTRO COCONUT DILL JERK ONION BASIL CHILES CUMIN GARLIC LEMON ORANGE BAY LEAF CINNAMON CURRY GINGER NUTMEG OREGANO THYME PARSLEY ROSEMARY PLEASE CHECK ALL YOU ENJOY EATING: ALMONDS BUCKWHEAT BLACK EYED FARRO LENTILS PEANUTS BARLEY BULGUR PEAS HAZELNUTS OATS PINE NUTS BLACKBEANS BRAZIL NUTS CHICKPEAS KIDNEY BEANS PECANS WALNUTS QUINOA SPELT WHITE BEANS DO YOU FEEL YOURSELF MINDLESSLY SNACKING DURING THE DAY? YES / NO IF YES, WHAT TIME(S:) DO YOU SUFFER FROM ANY SYMPTOMS BEFORE OR AFTER MEALS? PLEASE SPECIFY... _ ANYTHING ELSE YOU THINK I SHOULD KNOW?

My Diabetic Meal Plan during Pregnancy

My Diabetic Meal Plan during Pregnancy When you have diabetes and are pregnant, you need to eat small meals and s throughout the day to help control your blood sugar. This also helps you get in enough