Nutrition Questionnaire
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- Damian Warren
- 5 years ago
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1 Nutrition Questionnaire This office deals with the health, vitality and longevity of the individual. The following questions will help us to more accurately design a personalized program to allow you to reach your maximum health potential. Thank you for completing this form in its entirety and sending it back to Roni@specialtyhealthcareandwellness.com at least one week before your appointment. Name (Last, First, MI) Social Security Number Birthdate Gender Marital Status M S D Address Home Phone Cell Phone Work Phone Address Do not use to contact me Employer and Job Title Avg. number of hours per week spent working: Emergency Contact Name Contact Phone Referred by Personal Physician s Name Physician s Phone Preferred Pharmacy Name Pharmacy Phone GENERAL INFORMATION Reason for consultation: Desired outcome of consultation: What have you tried in the past to address your concerns that did not work: Have you experienced any of the following recently (check all that apply): Anxiety Brain fog Constipation Depression Diarrhea Dizziness/tingling Fatigue Fluid retention Headaches Irritability Joint pain Muscle loss Sinus/allergy issues Sleep disturbance Sore muscles Sugar cravings Swollen hands/feet Weight gain Weight loss (unwanted) Other (please explain) How important is it for you to resolve your health concerns on scale of 1-10 (1 being lowest)? How prepared/motivated are you to make the appropriate lifestyle changes that may be necessary in order to achieve your goals (1 being lowest)?
2 MEDICAL HISTORY Are you currently under the care of a healthcare professional for a medical/health condition: No Yes If yes, please describe condition(s): Please check any medical condition or health problems that you currently have or have had in the past: Condition Yes No Condition Yes No Headaches (Migraines) Seizure Disorder Recurrent Sinus Infections Seasonal Allergies Emotional/Psychiatric Illness Depression Anxiety/Excessive Stress Asthma Chronic Bronchitis Lung/Breathing Problems Chronic Indigestion Stomach Ulcers Intestinal Disease Skin Problems Back Pain/Sciatica Herniated Disc Neck Pain Chronic Muscle/Joint Pain Carpal Tunnel Syndrome Fibromyalgia Diabetes Thyroid Disease Osteoporosis/Osteopenia Heart Disease Chest Pain Irregular Heartbeat High Blood Pressure Blood Clotting Problems Bleeding Disorder Stroke/Vascular Disease Constipation/Diarrhea Hepatitis/Liver Disease Kidney Disease Menstrual Disorders Reproduction Problems Prostate Problems Sexual/Libido Problems Tendonitis Chronic Pain Shoulder Problems Osteoarthritis Rheumatoid Arthritis Artificial Joint(s) Cancer Psoriasis or Eczema Other (please list below) List any additional health problems not listed above: List any surgeries/operations you have had and when: Preventative Tests Month/Year of Last Test Test Results Cholesterol Vitamin/Mineral Test Thyroid
3 FAMILY HISTORY For the conditions listed below, check Yes or No if anyone in your family has been affected, then please note your relationship to that relative with that condition/disease on the adjacent line. Condition Yes No Relationship Autoimmune condition(s) Breast cancer Diabetes (Type 2) Colon cancer Heart disease Hypertension Ovarian/uterine cancer Prostate cancer Skin disorders Thyroid disease (hypo/hyper/hashimotos) Other cancer List any other disease/condition in your family and the relationship: FEMALE PERSONAL HISTORY Are you still menstruating? First day of last menstrual cycle? Do you have bleeding between periods? Are you pregnant? Have you ever been pregnant? How many pregnancies? Have you had a hysterectomy? Tubal Ligation? Do you still have your ovaries? Are you currently taking any hormones/oral contraceptives? Have you had any issues with them? Do you have uterine fibroids? Endometriosis? Menstrual irregularities? Date of last PAP smear Result Clinic / Doctor Name Date of last Mammogram (if applicable) Result Place performed MALE PERSONAL HISTORY Date of last physical: Result Clinic / Doctor Name Date of last prostate exam: Result Clinic / Doctor Name Are you concerned with a loss of muscle mass, tone or strength? No Yes Have you had problems with urination (decreased stream/frequent night urination)? No Yes Has your abdominal girth and weight been increasing? No Yes Do you have a desk job? No Yes Have you been told you have low testosterone? No Yes
4 MEDICATION/SUPPLEMENTATION List current medications (or those you have taken within the last year). Medication Name Date Started Date Stopped Dosage (amt /# daily) Nutritional supplements, vitamins, herbs, homeopathic remedies taken: Medication Allergies: Environmental/Food Allergies:
5 LIFESTYLE SUMMARY What are the challenges that prevent you from improving your diet and health? Tobacco: I have never smoked. I quit smoking in (mo/yr). I smoked packs/day for years. I use other tobacco products. I currently smoke packs/day. I have smoked for years. Alcohol: I never drink alcohol. I occasionally drink alcohol. I have a family history of alcoholism. I drink drinks per day/week/month (circle one). Diet: How many meals per week are consumed from fast food restaurants? How many meals per week are consumed from regular (not fast food) restaurants? How many alcoholic beverages do you have per week? How many sodas (diet or regular) do you consume per week? How many servings of refined sugar do you have per week? (desserts, candy, chocolate, sodas, etc) One serving equals about 100 calories. What are the three healthiest foods you eat each week: What are the three worst foods you eat each week: Please list any dietary restrictions/preferences you have: Exercise: I routinely exercise hours times per week. Please describe your current exercise routine, if you have one: Sleep: On weekdays I go to bed at and I am likely asleep by On weekdays my alarm goes off at and I get out of bed at On weekdays I wake up times per night On weekends I go to bed at and I am likely asleep by On weekends my alarm goes off at and I get out of bed at On weekends I wake up times per night In my bedroom (check all that apply): I use an alarm clock I watch TV before going to sleep I use phone/computer to surf the web I read a paper book I read on an electronic device
6 Food/Symptom Journal Name: Date: Write down everything you eat, drink and take (supplements and medications) for three days, including all snacks, beverages, and water. Please include approximate amounts. If you notice any mood or digestive changes associated with a meal/snack, record it in the right-hand column. Meal Beverages Mood/ Digestive Changes Breakfast (Time: ) Supplements/ Medications Lunch (Time: ) Dinner (Time: ) Bowel Movement(s): (Time: ) (Time: ) (Time: ) (Time: ) Normal Loose /diarrhea Hard Undigested food in stool Small pellets Painful Urgent S-Curve, formed Fatty, floating Lumpy Soft Sleep Pattern: I went to bed at and I was likely asleep by. I woke up at and got out of bed at. I woke up times last night. I felt before bed (ex. anxious, exhausted). Cravings: Exercise: Today I exercised for minutes. The kind of exercise I did was:.
7 Food/Symptom Journal Name: Date: Write down everything you eat, drink and take (supplements and medications) for three days, including all snacks, beverages, and water. Please include approximate amounts. If you notice any mood or digestive changes associated with a meal/snack, record it in the right-hand column. Meal Beverages Mood/ Digestive Changes Breakfast (Time: ) Supplements/ Medications Lunch (Time: ) Dinner (Time: ) Bowel Movement(s): (Time: ) (Time: ) (Time: ) (Time: ) Normal Loose /diarrhea Hard Undigested food in stool Small pellets Painful Urgent S-Curve, formed Fatty, floating Lumpy Soft Sleep Pattern: I went to bed at and I was likely asleep by. I woke up at and got out of bed at. I woke up times last night. I felt before bed (ex. anxious, exhausted). Cravings: Exercise: Today I exercised for minutes. The kind of exercise I did was:.
8 Food/Symptom Journal Name: Date: Write down everything you eat, drink and take (supplements and medications) for three days, including all snacks, beverages, and water. Please include approximate amounts. If you notice any mood or digestive changes associated with a meal/snack, record it in the right-hand column. Meal Beverages Mood/ Digestive Changes Breakfast (Time: ) Supplements/ Medications Lunch (Time: ) Dinner (Time: ) Bowel Movement(s): (Time: ) (Time: ) (Time: ) (Time: ) Normal Loose /diarrhea Hard Undigested food in stool Small pellets Painful Urgent S-Curve, formed Fatty, floating Lumpy Soft Sleep Pattern: I went to bed at and I was likely asleep by. I woke up at and got out of bed at. I woke up times last night. I felt before bed (ex. anxious, exhausted). Cravings: Exercise: Today I exercised for minutes. The kind of exercise I did was:.
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Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex
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Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:
Patient Profile Patient Name: DOB: Address: City: State: Zip: Phone# (H): (W): Other: Email: May Dr. Strong to leave medical information on your answering machine/voicemail? YES NO May Dr. Strong to send
Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation:
Name. Address. City. State Zip Code. Phone (day) Phone (cell) Phone (night) . Referred by. Age. Birth Date. Gender. Height.
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Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.
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Integrative Nutrition Intake
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Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Mercy Metabolic and Bariatric Surgery Program Questionnaire
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