Holistic Nutrition Questionnaire
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- Brenda Wilkins
- 5 years ago
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1 Kristin Arnett Holistic Nutrition Consultant Name: Height: Weight: Address: Date of birth: Age: Blood type: Phone Hm: Referred by: Work Cell: Holistic Nutrition Questionnaire Health Objectives What would you like to learn and gain from working with a nutrition consultant? (i.e. how foods affect an ailment, understanding of how the body works, lifestyle improvement, etc.) Health Background Describe any current health conditions that you are interested in addressing (onset, duration, frequency, etc): 1
2 How have you addressed these conditions (currently and in the past) (doctor, self-care, nutrition, acupuncture) and what has been the impact (positive and/or negative)? Personal Health History List Medications (include condition, i.e. Zoloft for depression) _ List Supplements (or attach separate page) Important: Include form, dosage, and frequency i.e. calcium citrate, 400mg twice/day Describe your health history as child (generally healthy, frequently sick, ear infections, etc.) Antibiotics: Describe how frequently you have taken antibiotics over the course of your life (include long term use for acne, short term courses, etc.). Do you have the following feelings/symptoms, how often? Spacey/fuzzy thinking Allergies/runny nose Eczema, rashes or skin conditions Yeast overgrowth (yeast infections, nail fungus, athlete s foot) Mood/Energy/Sleep Fatigue Depression Anxiety 2
3 Stress level (1-10; 1 low and 10 high) Occupation Do you like your work? How much sleep do you get What time do you go to bed, to sleep, and wake up Do you have trouble falling asleep Do you wake in the night? What time? Reason (i.e kids, mind)? How long does it take to fall back asleep? Body/Exercise Recent weight changes (gained or lost)? Do you want to change your weight? If so, how? Amount/type of Exercise: Women Do you still have menstrual periods? Number of days between cycles Length of period Are you pregnant? Trying to get pregnant? Nursing? Number of children and ages Do you have PMS, cramps, or any other imbalance? Digestion and elimination Do you have frequent gas or bloating? Does gas have a strong odor? Do you tend to have diarrhea or soft, unformed stool? Do you tend to have constipation? Do you have burping, heartburn or acid reflux? Do you take antacids or acid blockers? Describe any other digestive issues? How frequently to you have a bowel movement? What is consistency of stool? Formed like a brown banana Unformed, soft, or ribbon-like Small balls formed into banana, or rabbit-pellets Large diameter or anything else unusual 3
4 Dietary History Vegetarian (eat eggs and dairy) Yes / No Vegan (No eggs or dairy) Yes / No Eat fish? How often and what type? Do you have any known food allergies or sensitivities? Type of allergy testing (skin/scratch, IgE/IgG, muscle testing, dietary elimination)? Do you get headaches, joint pain, gut or other pain? Do you have any dietary restrictions Do you have any food cravings (sugar, carbs, fats) Do you consume: Coffee/caffeine Diet sodas Trans fats Soda MSG How much water do you drink per day? What type (tap, bottled, filtered) Describe dieting history or eating disorders? (i.e. Age, yo-yo dieting, calorie restriction, weight gain) Have you been diagnosed or believe you may have hypoglycemia Do you need to eat frequently? Do you get irritable, dizzy, headaches when you go too long without eating? Family History (indicate family member or self) Diabetes/Hypoglycemia Colitis/IBS Heart Disease Arthritis Cancer Autoimmune disorder Obesity Migraines/Headaches Depression, anxiety Alcoholism ADHD, Autism, LD Bipolar, schizophrenia Hyperactivity, tics Other 4
5 Toxic exposure: Have you had exposure to any toxins (pesticides, chemicals, heavy metals, plastics, inhaled chemicals, industrial chemicals) that you are aware of at your home or office? Have you received any vaccinations including the flu shot in the last few years? Are there any chemicals or smells that you are sensitive to (headaches, nausea)? Have you recently remodeled or plan to remodel your home? What did you have done? Do you consume or have exposure to the following, explain frequency: Artificial sweeteners Fluoridated water Chemical cleaning supplies Perfume/fragrance Fabric softener or drier sheets Tobacco Alcohol /recreational drugs 5
6 Kristin Arnett Holistic Nutrition Consultant Nutrition Consultant Service Agreement Last Name: I, am consulting with Kristin Arnett, a holistic nutrition consultant, to gain information on health and wellness. I understand that Kristin Arnett is not a physician and that she does not dispense medical advice nor prescribe treatment. Rather, she provides information to enhance my knowledge of how nutritious foods, herbs, supplements and lifestyle affect my life. Kristin Arnett s training includes a B.S. degree from Clayton College of Natural Health. Kristin is also certified as a Holistic Nutrition Consultant from the American Association of Drugless Practitioners. The methods of evaluation employed on my behalf, which may include diet, supplementation, and assessment analysis, are not intended to diagnose disease. I specifically authorize the use of such assessments to help to develop an appropriate dietary and health- supporting program for me, and to monitor my progress towards achieving my health goals. These services are not a substitute for medical care, and do not claim to diagnose, treat or alleviate disease. I understand that nutrition consultation services are not licensed by the state of Wisconsin and they are alternative or complementary to the healing arts services licensed by the state. For medical diagnosis and treatment of disease, I would need to consult with a medical or other licensed healing arts practitioner. By signing this agreement, I acknowledge that I have carefully read this document, and I understand its content and effect. I understand Kristin Arnett is not a licensed physician or a medical dietitian and that nutritional services are not licensed by the state of Wisconsin. I understand it is my responsibility to maintain a relationship with a medical doctor or other licensed health provider. I have consented to use the services offered by Kristin Arnett and I will be personally responsible for the payment of the associated fees of Kristin Arnett or Kristin s Kitchen LLC. I further agree to indemnify and holds harmless Kristin Arnett, Kristin s Kitchen LLC, Essential Yoga and employees therein, from any and all claims, actions, damages, or legal liabilities of any kind related to the services provided. Signature: Client Name: Date:
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1 Health Profile Date: / / / Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order
Child History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan
Child History Form (Ages 6-12) The data on this form is essential if we are to render the best professional care. We appreciate your cooperation in filling it out so that we will have accurate records.
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital