Client Nutrition Intake Form
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- Ada Hardy
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1 Client Nutrition Intake Form Date Information Name Age Address Phone (home) Phone (cell) Referred by MD/Other Health care practitioner info Stats Height Current Weight Ideal Weight Weight 1 Year Ago Family/Living Situation Occupation List any medications you are currently taking: List vitamins, minerals, herbs and other supplements (and amounts) you are now taking: Health Concerns What are your main health concerns? (Describe severity symptoms and when started): Please circle any of the following conditions that apply to your history and list date of onset: Anemia Arthritis Asthma Cancer Chronic fatigue Crohns or Ulcerative Colitis Diabetes Epilepsy Gallstones GERD/Reflux Gout Heart Attack Hepatitis High Cholesterol High Triglycerides High Blood Pressure Irritable Bowel Kidney Stones Mono Sinusitis Sleep Apnea Stroke Thyroid OTHER: Jane Schwartz, RD, CLT Page 1
2 How have you dealt with these concerns in the past? Doctors? Self Care? Any success? Have you experienced any success with these approaches? Have any other family members had similar problems (describe)? How often have you had antibiotics in infancy/childhood/teen adult? What about steroids? Nutritional Status Are there any foods that you avoid? If so, why? Do you have symptoms immediately after eating like bloating, gas, sneezing, hives? Explain Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain: Are there foods that you crave or even binge on? Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time. Which, if any, of the following foods do you consume regularly? soda diet soda refined sugar (sugar, honey, sweets, candy) alcohol fast food gluten (wheat, rye, barley) dairy (milk, cheese, yogurt) coffee other Do you feel better or worse eating certain types of foods? What percentage of your meals are home-cooked? Is there anything else I should know about your current diet, history, relationship to food? Jane Schwartz, RD, CLT Page 2
3 Intestinal Status Bowel Movement Frequency more than 3 times per day 2-3 times per day once a day not regularly every day (how many times per week) Bowel Movement Consistency 1) Separate hard lumps, like nuts (hard to pass) 2) Sausage-shaped, but lumpy 3) Like a sausage but with cracks on its surface 4) Like a sausage or snake, smooth and soft 5) Soft blobs with clear cut edges (passed easily) 6) Fluffy pieces with ragged edges, a mushy stool 7) Watery, no solid pieces. Entirely liquid Bowel Movement Color medium brown very dark or black greenish blood is visible variable yellow, light brown chalky colored greasy, shiny Do you experience intestinal gas or any itching: If so, please explain if it is excessive, odorous, etc Health Hazards 22. Have you been exposed to chemicals or toxic metals (lead, mercury, arsenic, aluminum)? 23. Do odors affect you? 24. Are you or have you been exposed to second-hand smoke? 25. Do you have mercury amalgam fillings? Lifestyle History Sleep and Stress Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Are you experiencing stress at this time in your life? Jane Schwartz, RD, CLT Page 3
4 How do you handle stress? Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night? What are your hobbies or leisure activities? For Women Only How are/were your menses? Do/did you have PMS? Painful periods: If so, explain. In the second half of your cycle do you experience any symptoms of breast tenderness, water retention or irritability? Have you experienced any yeast infections or urinary tract infections? Are they regular? Have you/do you still take birth control pills: If so, please list length of time and type. Have you had any problems with conception or pregnancy? Mental Health Status How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger? On a scale of 1 (worst)-10 (best), describe your usual level of energy. At what point in your life did you feel best? Why? Other Who in your family or on your health care team will be most supportive of you making dietary changes? Please describe any other information you think would be useful in helping to address your health concern(s): Jane Schwartz, RD, CLT Page 4
5 What are your health goals and aspirations? SUPPLEMENTAL 1. Please send or bring in any recent lab work. 2. Please write down on separate piece of paper everything you eat/drink for 3 days; include time of day Jane Schwartz, RD, CLT Page 5
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