Pregnancy Nutrition Intake. Name: Height: Weight: Address: Date of birth: Age: Blood type:
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1 Pregnancy Nutrition Intake Name: Height: Weight: Address: Date of birth: Age: Blood type: Phone Hm: Referred by: Work Cell: Baby s Due Date: What week of pregnancy are you in? Are you experiencing morning sickness at this point? Do you have any other children (names, ages)? Describe those pregnancies and births 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 Do have any current health conditions that you are interested in addressing (onset, duration, frequency, etc). How have you addressed these conditions?: (415)
2 Personal Health History What practitioners are you currently seeing? May I contact them with your permission? Do you have an OB or midwife? Name Specialty/condition Phone Permission 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.). Any courses while pregnant? 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 Stress level (1-10; 1 low and 10 high) Occupation Do you like your work? (415)
3 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)? Amount/type of Exercise: 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 (415)
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 Soda Processed food 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/Gestational Diabetes Colitis/IBS Heart Disease Arthritis Cancer Autoimmune disorder Obesity Migraines/Headaches Depression, anxiety Alcoholism ADHD, Autism, LD Bipolar, schizophrenia Hyperactivity, tics Other (415)
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 (415)
6 Food/Mood Record 1. Please write out your daily diet. Fill out a diet record for at least two days. Include portion size and any supplements or medications. Include time of day. 2. Additionally, record any symptoms you feel during or after eating, such as drowsy, irritable, energized. Time Food/Supplements Mood/Energy/Symptoms Example 9:00 1 cup of Cheerios with 3/4 c cow milk 10:00 Feel fine 1 multi-vit/min, 500 mg vit C 11:00 Low energy, stressed Breakfast Snack Lunch Snack Dinner Night-time Eating How much and what type of beverages do you drink each day: Water Fruit juices (type) Juice drinks Milk Soft drinks (sugar or diet) Other (415)
7 Food/Mood Record 1. Please write out your daily diet. Fill out a diet record for at least two days. Include portion size and any supplements or medications. Include time of day. 2. Additionally, record any symptoms you feel during or after eating, such as drowsy, irritable, energized. Time Food/Supplements Mood/Energy/Symptoms Example 9:00 1 cup of Cheerios with 3/4 c cow milk 10:00 Feel fine 1 multi-vit/min, 500 mg vit C 11:00 Low energy, stressed Breakfast Snack Lunch Snack Dinner Night-time Eating How much and what type of beverages do you drink each day: Water Fruit juices (type) Juice drinks Milk Soft drinks (sugar or diet) Other (415)
8 Nutrition Consultant Service Agreement I,, am consulting with to gain information on health and wellness. I understand that Julie Matthews 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 health. Julie Matthews training includes a seven hundred hour certification program in nutrition education and consultation from Bauman College. 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 these assessments, so that we can develop an appropriate dietary and health-supporting program for me and/or my child, 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. Nutrition consultation services are not licensed by the state of California, 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 physician, or other licensed healing arts practitioner. I am acting solely on my own behalf. I do not represent any other person, entity, and/or governmental agency. I currently am am not under the care of a physician for a health problem or medical condition. I give Julie Matthews permission to contact my physician,, at the following phone number on my behalf. The purpose of this contact would be to attain additional information from my doctor on his/her diagnosis or recommended treatment, in order that Ms. Matthews may best provide me with appropriate and complementary information. I know that Julie is not, and cannot be, a primary healthcare provider. I agree to hold Julie Matthews and Healthful Living harmless for any claims or damages in association with our work together. This is a contract between Julie Matthews/Healthful Living and myself and a general release of liability for Julie Matthews and Healthful Living. I understand Healthful Living has a 48-hour cancellation policy, and am aware that I will be charged a $50 cancellation fee for a missed appointment if proper notice is not given (by phone NOT ). For prepaid and discounted Appointment Packages, unused portions are not refundable. It is highly recommended that Appointment Packages be fully utilized within 6 months of their original purchase date, as this best serves client and practitioner objectives for motivation and timely results. Portions of prepaid packages will be forfeited if unused after 9 months. Signature: Client Name: Date: {Please keep a copy for your records} (415)
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