Nutrition Questionnaire Having suboptimal health can be detrimental to quality of life. Luckily, there are many ways to recover your health through diet and lifestyle changes. This questionnaire will help determine where our focus should be, and what routes we need to take to determine underlying causes of your illness. Please answer each question to the best of your ability. The information, materials and content within this assessment are intended as general guidance only and are not to be considered a substitute for professional medical advice, diagnosis, or treatment. Name DOB Age Today s Date / / / / Mailing Address City State Zip Home Phone Cell Phone Email ( ) ( ) Occupation Employer/School Work Status Full-time Part-time Seasonal Other: Emergency Contact Phone Relationship to You ( ) Height Weight Gender Have you ever had changes in weight (intentional or not)? PLEASE LIST CURRENT AND ONGOING SYMPTOMS IN ORDER OF SEVERITY Complaint / Symptom For how long? Treatment(s) tried Treatment outcome What was the determining factor in seeking help? What triggers these symptoms? What makes the symptoms better?
PLEASE INDICATE ANY CONDITIONS OR PROCEDURES YOU PREVIOUSLY OR CURRENTLY HAVE Illness X if yes If Y, how long? Illness X if yes If Y, how long? Anemia Gallstones Asthma Gout Arthritis Heart Attack Cancer Heart Disease Chronic Fatigue Syndrome High Cholesterol Diabetes High Blood Pressure Epilepsy HIV Illness X if yes If Y, how long? Illness X if yes If Y, how long? Hypoglycemia Rheumatoid Arthritis Irritable Bowel Disease Sinusitis Kidney Stones Sleep Apnea Lyme Disease Stroke Mononucleosis Thyroid Disorder Pneumonia Endometriosis Polycystic Ovarian Syndrome COPD Alcoholism Cold Sores Deep Vein Thrombosis Eczema / Psoriasis Goiter Hepatitis A / B / C Tumor(s) Ulcer(s) Joint Pain Osteoporosis Other: Past Surgeries & Injuries (include dental work, broken bones, concussions, strains/sprains, etc.) Have you had any medical scans (CAT, MRI, ultrasounds, organ scan, etc.)? What was the result? Any current blood work? Results? CHILDHOOD QUESTIONNAIRE Were you born vaginally or via c-section? Were you born premature? Were you bottle or breast fed?
How often, and for how long, did you take antibiotics? FEMALES ONLY Age your periods began Date of last menstrual cycle Are you currently pregnant? Trying to conceive? Please circle any contraceptives you have used or are currently using Birth Control Pills Hormone Replacement Contraceptive Shot Hormone IUD Copper IUD Emergency Contraceptives Vaginal Ring Contraceptive Patch Are your cycles regular? Yes No Are you in perimenopause? Yes No Are you postmenopausal? Yes No Having difficulty getting pregnant? Yes No # of pregnancies # of children birthed # of c-sections # of miscarriages Age(s) of child(ren) Please describe your pregnancy(s) and labor(s) How much water do you drink per day? What type of caffeinated beverage do you drink? How often? Are you currently, or have you ever, followed a specific diet (paleo, vegan, etc)? If so, what was the reasoning? How long did it last? Was it successful? What made it challenging? How often do you eat out? What restaurants do you typically go to? Do you eat when you feel (circle all that apply) Happy Sad Stressed Lonely Bored Anxious Other: What foods do you reach for during these times? Do you crave desserts and sweet foods? When and how often?
Family History Please list all family members with specific health complications (Allergies, Alzheimer s, Autoimmune disorders, Cancer, Cardiovascular disease, Depression, Diabetes, Gallbladder disorders, High cholesterol/blood pressure/triglycerides, Obesity, Stroke, etc.) Disease or Condition Family Member Please let us know of any other information that you feel would be relevant Environmental Contributors Rate your current stress level from 1 (none) to 10 (highest) Why? What do you do when you are feeling stressed (Eat, go for a walk, talk to a friend, etc) Are you currently experiencing any major life changes? yes no Do you have difficulty sleeping? Falling asleep? Staying asleep? yes no Do you crash halfway through the day? yes no Do you have random bouts of irritability? yes no Do you use a lot of plastic products daily? yes no Do you microwave food in plastic? yes no Do you use products with fragrance? yes no Do you drink tap water? yes no If you don t drink tap water, what type of water do you drink? What type of cookware do you use? Non-stick Cast iron Stainless Steel Ceramic Glass Other: Do you know of, and follow, the Dirty Dozen or Clean Fifteen? (If not, we will discuss.) Social History Marital Status Married Divorced Separated Single Other: Who do you live with? Please list all parents, children, spouse, relatives, and friends
Have you experienced any major losses in life? If yes, please comment. Is religion, or spirituality, important in your everyday life? Do you enjoy going to work? How many sick days do you usually use per year? What previous jobs have you had? (List duration as well.) Do you travel for work? If so, where? Who do you eat meals with? How often do you drink alcoholic beverages? Never 2-3 times per year 2-3 times per month 2-3 times per week Other: Do you smoke cigarettes? If yes, how many per day? How long have you been a smoker? Illegal drug use (current or previous)? yes no What are your hobbies? Are you part of a community group? If yes, which one(s)? yes no Liver & Gallbladder: Do you have, or have you had, any of the following? Symptom / Condition X if yes Symptom / Condition X if yes Pain between shoulder blades Stomach upset by greasy foods Light or clay colored stools Motion sickness Morning sickness Dy skin, itchy or peeling feet? Headache over eyes Gallbladder attacks Gallbladder removed Bitter taste in mouth, esp after food Become sick after drinking wine Easily intoxicated by drinking wine Easily hungover after drinking wine Recovering alcoholic or prev. drug use Long-term use of prescrip. or rec. drugs Sensitive to chemicals Sensitive to tobacco smoke Pain under right side of rib cage Chronic fatigue Fibromyalgia
MALE HORMONES (If female, skip to the next section): Please circle all that apply Basic Hormonal Profile: Burned out feeling Irritable Insomnia Decreased urine flow Hot flashes Erectile dysfunction Increased urinary urge Decreased stamina Weight gain in waist Prostate problems Infertility problems Sleep disturbances Decreased libido Decreased mental sharpness Oily skin Decreased muscle mass Night sweats Apathy Adrenal Hormones Aches and pains Elevated triglycerides Morning fatigue Bone loss Sleep disturbances Lack of motivation Allergic conditions Autoimmune illness Fibromyalgia Stress Evening fatigue Susceptibility to infection Low body temperature Inability to concentrate Excessive hunger Digestive dysfunction Low blood pressure Heart palpitations Dizziness upon standing Sweet / salt cravings Thyroid Hormones Low libido Depression Foggy thinking Cold body temperature Headache Fatigue Constipation Elevated cholesterol Lack of motivation Inability to lose weight Other High blood sugar High blood pressure Overweight / obese Weight gain Sugar cravings Low physical activity Waist size >40 Family history of heart disease Family history of diabetes FEMALE HORMONES (If male, skip to the next section): Please circle all that apply Basic Hormonal Profile Hot flashes Mood swings PMS symptoms PMDD symptoms Urinary incontinence Night sweats Heart palpitations Cystic ovaries (PCOS) Endometriosis Vaginal dryness Acne Heavy menses Foggy thinking Weight gain Depressed mood Irritability Increased body/facial hair Headaches Bone loss Uterine fibroids Thinning skin Fibrocystic breasts Infertility Adrenal Hormones Aches and pains Elevated triglycerides Morning fatigue Sleep disturbances Depression Anxiety Blood sugar imbalance Nervousness Allergic conditions Autoimmune illness Chronic illness Evening fatigue Low body temperature Inability to concentrate Excessive hunger Digestive dysfunction Low blood pressure Heart palpitations Dizziness upon standing Sweet / salt cravings Thyroid Hormones Aches and pains Brittle nails Cold hands and feet Dry skin Headaches Foggy thinking Weight gain Feeling cold all the time Heart palpitations Low libido Inability to lose weight Sleep disturbances Constipation Thinning hair Menstrual irregularities Elevated cholesterol Other High blood sugar High blood pressure Overweight / obese Weight gain Sugar cravings Low physical activity Waist size >35 Family history of heart disease Family history of diabetes
INFLAMMATION: Do you have, or have you ever had, any of the following (please circle): Joint pain Joint stiffness Loss of movement in joints Red, swollen joints Fatigue Stomach pain Headaches Muscle pain Other: FATTY ACID IMBALANCE Have you ever been told you have a fatty liver? yes no Please indicate if you have any of the following Scaly skin Difficulty getting pregnant Poor concentration Tingling in arms or legs Behavior disturbances Impaired growth (youth) Increased thirst Loss of hair Poor wound healing Depression Weakness Anxiety Rheumatoid arthritis Chronic inflammation Immune dysfunction Gallstones GASTROINTESTINAL SYSTEM Do certain foods cause symptoms immediately (belching, bloating, fatigue, etc)? yes no If yes, please explain (e.g., milk gas + bloating) Do you have delayed symptoms after eating certain foods (muscle aches, congestion, etc)? yes no If yes, please explain (e.g., wheat joint pain) Do you feel worse after eating (Y / N): High fat foods High protein foods High carbohydrate foods High fiber foods Refined sugar Fried foods Alcoholic beverages (moderate amount) Do you feel better after eating (Y / N): High fat foods High protein foods High carbohydrate foods High fiber foods Refined sugar Fried foods Alcoholic beverages (moderate amount) Do you feel better when you skip meals? yes no Do you get shaky, dizzy, or lightheaded when missing a meal? yes no What foods do you typically crave? Do you get intestinal gas? Daily Occasionally Foul odor Painful Do your stools appear shiny or greasy? yes no How often do you have bowel movements? More than 1 a day 1 a day 4-6 per week 2-3 per week <1 per week What is the typical consistency of your stool? E.g., soft and cylinder, small and hard, contains undigested foods