Nutrition Consultation Intake Form Please write or print clearly

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Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print clearly PATIENT INFORMATION: Date: Name (First / MI / Last): Address Line 1: Address Line 2: City: State: Zip Code: Telephone Work: Home: Mobile: Email address: Relationships status: Occupation: How often do you check email? Children? Hours of work per week: Sex: Age: Date of Birth: Place of Birth: Ethnic Background: Height: Frame Size (S,M,L): Current weight: Weight six months ago: One year ago: Would you like your weight to be different? Desired Weight: Have you seen a nutritionist before? Referred by (physician, friend, other)? MEDICAL HISTORY: Date of Last Physical Exam: Date of Last Full Bloodwork: Blood Type (A, AB, B, O): List serious illnesses/ hospitalizations/ injuries/ infections / operations / diagnostic (indicate year)? Are there any doctors, healers, helpers or therapies with which you are involved? Please list: 2015 Artemis in the City, LLC www.artemisinthecity.com 1

MEDICAL HISTORY: Please note with an x if you have been diagnosed with any of the following. List the year you were diagnosed or experienced the symptoms and also describe/specify where necessary. Disease / Illness / Symptom Current: Past: Describe/Specify Acne AIDs or HIV+ Alcohol or Drug Addiction (specify) Allergies (specify) Alzheimer s Disease /Vascular Dementia/ Memory Issues (specify) Anemia Anxiety or Panic Attacks (specify) Arthritis (osteoarthritis or rheumatoid) (specify) Asthma / Breathing Issues (specify) Autism Autoimmune condition (specify) Bad Breath Bleeding Tendency (specify) Blood Transfusions Brain Fog Bronchitis Cancer (specify type) Chickenpox / Shingles (specify) Chronic Fatigue Syndrome Cold Hands and Feet Cold Sores / Herpes Virus Dental or Mouth Issues (specify) Dehydration Depression/Mood Disorders/Bipolar (specify) Diabetes (specify type) Digestive Disorders / Gastrointestinal Disorders (specify) Diarrhea / Constipation (specify) Dry itchy skin, rashes, hives, dermatitis (specify) Eating Disorder (specify) Eczema or Psoriasis (specify) Emphysema Exposure to Environmental Toxins (specify) Epilepsy, convulsions or seizures (specify) Eye Disease / Glaucoma / Vision Issues / Dry (specify) Fibromyalgia Food Allergies or Sensitivities Frequent Illness Fungal Infection:Candida/Yeast, Athlete s Foot, Ringworm(specify) Gallbladder Disease / Gallstones (specify type) Gas / Bloating / Belching Genital Issues (specify) Gout Hairloss Heart Attack / Angina Heartburn / Acid Reflux (specify) Heart Disease / Cardio Vascular Disease (specify) Hemorrhoids Hepatitis Hernia High Blood Fats (cholesterol, triglycerides) 2015 Artemis in the City, LLC www.artemisinthecity.com 2

Disease / Illness / Symptom Current: Past: Describe/Specify High Blood Pressure (hypertension) Hyperactivity Hypoglycemia (low blood sugar) Intestinal Disease (specify) Inflammatory Bowel Disease (Crohn s or Ulcerative Colitis) Infertility Irritable Bowel Syndrome (IBS) Kidney Disease / Failure or Kidney Stones (specify) Lung Disease (specify) Liver Disease Low Libido (Sex Drive) Measles Mental Health Issues (specify) Migraine Headaches Mitral Valve Prolapse Mononucleosis (Epstein Barr Virus) Multiple Sclerosis Muscle Cramps Muscular Dystrophy Mumps Nausea Neuropathy Numbness or Tingling (specify) Obesity Osteoporosis Pacemaker or other Medical Device (specify) Pain / Inflammation (specify) Parasitic Worms Parkinson s Disease PMS Polycystic Ovarian Syndrome (PCOS) Pneumonia Prostate Problems Restless Leg Syndrome Ringing in Ears Sexually Transmitted Disease (Herpes, HPV, Other) (specify) Sinus Issues Sleep Disorder / Apnea / Insomnia (specify) Stroke Thyroid Disease (specify) Tuberculosis Ulcers (specify) Urinary Issues (specify) Vomiting Weight-loss / Underweight Other: SLEEP: Do you sleep well? Do you wake up at night? What times? To urinate? What time do you go to sleep? What time do you generally get up in the morning? How many hours of sleep? 2015 Artemis in the City, LLC www.artemisinthecity.com 3

BOWEL MOVEMENT: Constipation/Diarrhea? Number of times? per day? per week? Describe Consistency (Hard, Loose, Oily, Watery, Smooth Formed, Other): Describe Color (Light Brown, Medium Brown, Dark Brown, Other): Do BMs float or sink? Are BMs hard to pass? WOMEN: Are your periods regular? How many days is your flow? How frequent? Painful or symptomatic? Please explain: Are you pregnant? Fertility Issues? Menopause? Breast Issues/Fibroids? Ovarian Cysts/Fibroids? Hormone Issues? Additional (Itching, Dryness, Discharge, Other): Taking Birth Control Medication or Hormone Replacement or have taken in the past? ALLERGIES / SENSITIVITIES: Allergies (Severe/Life Threatening): Sensitivities (Mild to Moderate): Drugs: Foods: Environmental Sources: Other: Have had allergy testing? Would like allergy testing? FAMILY HISTORY: Describe the health of your family members (include weight, cancer, heart disease, diabetes, high blood pressure, high cholesterol, genetic disorders and other): Mother Father Siblings Grandparents Aunts / Uncles Cousins Children MEDICATIONS / SUPPLEMENTS: Do you take any vitamins or medications? If so, which? 2015 Artemis in the City, LLC www.artemisinthecity.com 4

NUTRITION & LIFESTYLE: What role does exercise play in your life? Do you drink coffee, alcohol, smoke cigarettes, or have any major addictions? What percentage of your food is home cooked? Where do you get the rest from? How do you feel about food, cooking and shopping? Any dietary restrictions (religious, vegan, vegetarian, kosher, gluten-free)? What are your top concerns? Nutrition and health goals? What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What s your food like these days? List what you consumed over the last 24 hours. Breakfast Lunch Dinner Snacks Liquids PLAN OF ACTION NOTES: (to be completed by nutritionist) 2015 Artemis in the City, LLC www.artemisinthecity.com 5

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