Nutrition Analysis Guide

Transcription

1 Nutrition Analysis Guide Date: First & Last Name: Phone Number: Age: Sex: Weight: Height: #of Children: Desired Weight: Weight 6 Months ago Relationship Status Main Health Concerns: Other Health Concerns/Goals Please write down everything you eat and drink for the next three days as accurately as possible. Also, include coffee, alcoholic beverages, soda, candy, etc., and estimated serving sizes whenever possible. Try to be specific. For example, instead of writing 1 cup of milk, specify if the milk was low fat, 2% or nonfat. Explain in detail how the food was prepared. For example, instead of writing 1 chicken breast, describe whether the chicken was fried, baked or grilled, what kind of oil was used, if it was breaded, and so forth. Please leave the areas blank. Day 1 Breakfast: Lunch:

2 Dinner: Snacks: Day 2 Breakfast: Lunch: Dinner: Snacks: Day 3 Breakfast: Lunch:

3 Dinner: Snacks: Is the above an accurate representation of your overall diet? Yes No If no, please explain what you do differently: : What time do you eat your last meal? : Do you eat breakfast on a regular basis? Yes No :

4 Do you cook at home most of the time? Or eat out most of the time? : Answer the following questions to the best of your ability. If there is something you are unsure about, leave it blank and discuss it with your Nutritional Consultant. Serving size generally equals one cup or 3 1/2 ounces. These figures do not have to be exact, just give the most accurate guess you can. 1. How many glasses of purified water do you drink per day? 2. How many servings of fresh fruits/vegetables to you eat per day? 3. How many servings of low fat protein (beans, fish, skinless chicken breast, turkey breast, extra lean beef) do you eat per day?

5 4. Home many servings of complex carbohydrates (bran, whole grains, starchy vegetables) do you eat per day? 5. Do you drink fresh fruit/vegetable juices everyday? 6. Do you eat organic fruits/vegetables everyday? 7. How many cups of coffee, soda, black tea do you drink per day? 8. How many refined sugar items (candy bars, donuts, cookies, cakes, etc) do you eat per day? How many contain artificial sweeteners (Sweet-n-Low, Splenda, Equal, etc)?

6 9. How many fast food items (Hamburgers, Hotdogs, Frozen Dinners, Canned Foods, French Fries, etc) do you eat per day? 10. How many servings of bread, pasta, and other processed carbohydrates do you eat per day? 11. How many servings of dairy do you eat per day? 12. How many servings of processed or smoked meats (salami, ham, hot dogs, sausages, boloney, etc) do you eat per day? 13. Do you smoke or use tobacco products? Yes No If yes, how much?

7 14. Do you take over-the-counter drugs? What kind? 15. Do you take nutritional supplements (vitamins, minerals, digestive enzymes, amino acids, herbs, etc) on a daily basis? Yes No If yes, please describe in detail, including dosages, time, and frequency: 16. How would you grade your knowledge of nutritional supplements? Excellent? Fairly Good? Poor? 17. How many days a week to you exercise a minimum of 30 minutes?

8 18. What is your occupation? How would you describe your job (mark as many as applies): Physical Mental Stressful Easy Going Secure Non-Secure Exhausting Relaxing? 19. How many hours do you work in an average week? 20. Does anyone smoke in your home? Yes No 21. Mark any potentially harmful elements you regularly come in contact with at home or at work: Humidity Mildew Poor Ventilation Air Conditioning Carpet (over 4yrs. Old) High traffic road near by Smog Fluorescent lighting Strong cleaners Insect repellents Lawn and garden chemicals 22. Do you suffer from Candida Albicans? Yes No Not Sure

9 23. When was your last physical exam with a primary physician? Blood Work? If comfortable, you may provide me a copy when returning this Analysis Guide. 24. How do you sleep? 25. How many hours on average do you sleep? 26. Wake during the night? Why? 27. Any pain, stiffness or swelling? Explain 28.Constipation/Diarrhea/Gas/Gurd? Triggers? 29. Allergies or Sensitivities? Explain 30. Last Period 31. HRT?

10 BMI Calculation: Consultant s further comments and suggestions:

11 CONSENT, DISCLOSER AND CONSENT FORM I REQUEST Lisa Mittry, CNC perform an evaluation and set up a program for the purpose of enhancing health. I UNDERSTAND that Lisa Mittry is a Certified Nutrition Consultant. I UNDERSTAND that a Nutritional Evaluation is not intended as a diagnosis, prescription, or treatment for any disease, physical or mental. Nor is the evaluation intended as a substitute for regular medical care. Print Name DATE Signature DATE

12 NAME HEALTH APPRAISAL - BRIEF DATE CIRCLEthe number which best describes the frequency of your symptoms. If you do not know the answer to the question, leave it blank. When you are finished, please add the number of points in each section and enter the number in the Total Point box. The score for YES is the number inside the parenthesis ( ). (0) never or rarely (1) twice a week or less (2) three to six times a week (3) daily or several times a day PART I Section A Section C 1. Indigestion Stomach pain. burning, 2. Belching, burping aching '4 hours after eating Gas immediately following a meal Feeling hungry an hour or two after eating 4. Sense of fullness during meals Stomach discomfort, pain in 5. Poor appetite, picky eater response to strong emotions, 6. Difficult bowel movements thoughts, smell of food Difficulty swallowing Heartburn, especially when 8. History of anemia, lying down, bending forward unresponsive to iron N Y (10) 5. Heartburn due to spicy and 9. Vegetarian (no eggs, dairy) N Y (5) fatty foods, chocolate, peppers, 10. Spoon shaped nails N Y (3) citrus, alcohol, caffeine Unintentional weight loss N Y (3) 6. Difficulty or pain when swallowing Partial loss of taste or smell N Y (3) 7. Chest pain or infections, difficulty breathing Total Points 8. Experience relief from carbonated beverages, cream/milk/food Section B 9. Constipation Indigestion and fullness lasts 10. Black, tarry stool hours after eating Pain, tenderness, soreness Total Points. on left side under rib cage Section 0 3. Bloated lower abdominal pain, 4. Excessive passage of gas cramping and/or spasms Abdominal cramps, aches lower abdominal pain relief 6. Nausea and/or vomiting by passing stool or gas Specific foods/beverages 3. Raw fruits, vegetables and aggravate indigestion stress aggravate bowel pain Roughage and fiber causes 4. Diarrhea (loose watery stool) constipation More than three bowel 9. Three or more large bowel movements daily movements daily Excessive gas and bloating Alternating constipation 7. Painful, difficult,straining and diarrhea during bowel movements Undigested food in stool Hard, dry or small stool, Mucus in stool Extremely narrow stools Dry, flaky skin, dry brittle hair N Y (3) 10. Alternating diarrhea/constipation Difficulty gaining weight N Y (3) 11. Mucus, pus in stool Feeling that bowels do not Total Points empty completely Bright red blood following bowel movement Anal itching PART II Total Points Section A 12. Fatigue, weakness, exhaustion Moderate to severe pain 13. Unable to concentrate, under right side of rib cage irritable, confused Abdominal pain worsens 14. Swollen feet and/or legs with deep breathing Easy bruising 3. Regurgitate bitter fluid Feeling of extreme dryness 4. Bloated, full feeling Reddened skin, especially palms 5. Belching, heartburn, gas Dark urine, diminished flow 6. Fatty foods cause indigestion Dry, flaky skin, hair N Y (3) 7. Nausea or vomiting Feel restless, agitated Yellowish cast to skin, eyes N Y (3) 3 9. Unexplained itchy skin worse at night Stool color alternates from Section B Total Points clay colored to normal brown Fatigue, sluggish Feeling of poor health Feel cold, [i.e. hands and feet) e 1995l)f3 Heller and Michael Katke. All rights reserved. Photocopying without permission is strictly prohibited by law.

13 Section 8 (continued) 13. loss of appetite Difficult, infrequent bowel 14. Abdominal swelling movements Unsteady gait, movements Dryness - skin, hair lack of interest in sex Thick, brittle nails Premenstrual tension N Y (3) 6. Outer third of eyebrow thins Infertil ity N Y (3) 7. Puffy face, hands and feet Heavy menstrual bleeding N Y (3) 8. Swollen upper eyelids Gain weight easily N Y (10) 9. Eyeballs move involuntarily Swelling of the neck N Y (10) 10. Muscles weak, cramp 22. Thinning hair on scalp, face and/or tremble and genitals N Y (3) 11. Slow mental processes, forgetfulness Total Points. 12. Slow heart beats PART III 1. Progressive, mild fatigue after 10. Indigestion exertion or stress Blotchy skin (white patches) General weakness Tan skin, no sun Blurred vision, dizzy when rising Black freckles on upper 4. Depression forehead, face, neck Rapid mood swings Craving for salty foods Irritable, nervous Gradual loss of body hair N Y (3) 7. Dark circles under the eyes Sensitive to subtle changes 8. Disinterest in food in surroundings, weather N Y (5) 9. Abdominal pain Total Points. PART IV Section A Section 8 (continued) 1. Generalized bone 13. legs move during sleep tenderness and achiness Numbing, tingling sensation localized bone pain Excessivejoint mobility Bone deformity or swelling Unable to fully straighten or 4. Shins hurt during or after exercises extend legs and/or arms low back or hip pain Upper or lower back pain limp, walking difficulties Crunching or creaking Total Points. sounds when move joints Section C 8. Hands, feet, throat spasm, 1. Joint stiffness, soreness feel numb Red, swollen painful joints Joint pain and stiffness - especially in spine, hips, knees Joint stiffness worsens with rest, improves with moving Hearing loss, headaches, ringing in ears Cracking joints Established bone loss N Y (10) 5. Shooting, aching, tingling pain down the back of leg Calcium deposits N Y (5) 6. Joint pain involves one or 13. Spinal curvature N Y (10) a few joints Recent loss of height N Y (10) 7. Joints hurt when moving or 15. Bow legs N Y (5) when carrying weight Stooped posture N Y (5) 8. limited range of motion Hump at base of neck N Y (5) 9. Difficulty standing up 18. Unexplained bone fracture N Y (10) from sitting position Tooth loss, gum disease N Y (3) 10. Joint stiffness improves with rest, worsens with moving Total Points 11. Headache Section Difficulty chewing food or opening mouth General muscle ache, pains Numbness, prickling, 2. localized muscle stiffness, tingling sensation in the tension, pain neck, shoulder and arms Specific points on body feel 14. Involuntary muscle spasms sore when presses Deliberate movement with hands 4. Headaches is difficult Fatigue, tired, sluggish Injure, strain, sprain easily Difficulty sleeping Discomfort or pain in neck, 7. Feel unrefreshed upon awakening shoulder or arm Muscle weakness or loss Knobby overgrowths on the 9. Difficulty speaking swallowing joints closest to the fingertips N Y (5) 10. Muscle cramps or spasm Double jointed N Y (5) 11. Muscles twitch or tremble One leg shorter than the other N Y (5) eyelids, thumb, calf muscle Irresistible urge to move legs Total Points. MET011 Rev. 10/97

14 I II III IV Gastrointestinal Detox Adrenal Musculoskeletal Metabolism Q) '" Q) '" Q; ::J Q) t; "0 c.~ '" ~ C "0 i= '''::: (\1 C "0 C Q) ;Q '" OJ 0 '6 ~~ '12 ~ > '0.E c u (ij >- - <.) ~ tl _ 'r:: o c Q) o :g Q) '" c '" 0 mg c ::J C C ::J Q) (3 C g; (j)(;j Q) a. '" ~1i) C C E x "'>- 0 > >- "0>- 0 '" ::J 0 ::r:: (f)w (!l0 0 ::::; ::r:: «0 co :;; 0 «ai o ci «ai ««ai c.:i > l:t::: 12 Oa: l:- 13 a: a r r W>.!;:ct- a: a: WO C- 5 Oa: ~c r f I ~~ -.JQ 3 Oa: a: a. 0 INITIAL SCORE NAME _ INITIAL TEST DATE NOTES RETEST DATE _ ::J: CI) C» ;:; ::r l> "C "C OJ ui' C» G') OJ "C ::r OJ :!:! m." RETEST SCORE ~ 1995 Lyra Heller and Michael Katka. All rights reserved. Photocopying without permission is strictly prohibited by law. MET012 Rev.1/00