Nutritional and non-nutritional habits Running title: and ...
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Lifestyle and Nutritional Assessment FormDear Client: Please read the instructions of each form carefully and complete this questionnaire with care. Your answers will help me determine the most effective recommendations to make based on your main health concern(s) presented. This health history record is protected and kept strictly confidential. It will not be released without your consent.
Name: Date:
Telephone (Home): (Work): (Cell):
Email:
Age:
Sex: M F
Height:
Weight:
Appointment Reminders? No Email Phone AHS Quarterly Newsletters? Yes No
Please answer each question carefully and LEAVE BLANK those that don’t apply to you.
LIFESTYLE:What is your #1 goal you want to achieve during our time together?
What are your main health concerns? Please list concerns in priority and when they started:
1. 4.
2. 5.
3. 6.
Have you ever experienced any major trauma? What level of stress do you currently experience? Please quantify on a scale of 1 (low) to 10 (high): What are the major causes of your stress? How does your stress manifest (show)? What coping mechanisms do you implement? Do you vacation regularly? Yes No What was your last vacation?
What is your current exercise routine? (Include type, frequency and duration)
Are you satisfied with your present weight? Yes No Do you wish to gain weight? lose weight? If so, how much?
How would you describe your energy levels on a scale of 1 (low) to 10 (high)? Do you experience any lulls or highs in energy levels throughout the day? Yes No If so, what time(s) of day?
How many hours on average do you sleep daily? Do you: have difficulty falling asleep? Staying asleep? Awaken feeling unrested? Snore?
What is your occupation? What do you enjoy/not enjoy about work? How many hours each week do you work? Do you work shifts? Regular schedule?
Do you smoke? Yes No If yes, how much and for how long? How do you feel about smoking?
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Are you ever exposed to smoke at home or at work? Yes No Do you use recreational drugs? Yes No If yes, please describe: Have you ever been treated for: drug dependency? Alcohol dependency?
How many hours do you spend daily, on average: Driving? Watching TV?
Reading? On a computer?
Sitting at a desk?
What is your current morning routine? Evening routine?
What are your interests and hobbies? Please list: How much free time do you feel you have in a day? If need be, how would you make more time for yourself? Do you regularly check in with yourself (self-reflect)? Yes No Need reminders to do so Time permitting, what would you like to incorporate into your day?
MEDICAL HISTORY:Are you currently taking medication (including birth control)? Yes No
Name of Prescription Medication
Reason(s) for Medication Duration of Medication
Have you taken antibiotics over the past 5 years? Yes No If yes, when were they last taken and the reason for taking it?
Are you currently taking Natural Health Products (NHPs)? (Includes vitamins, minerals, herbs and homeopathic remedies) Yes No
Name of NHP Reason(s) for NHP Daily Amount/Dose
Do you have any allergies or sensitivities (including to medication)? Yes No If so, please list: Are you anaphylactic (life-threatening allergy)? If so, to what:
Do you have any silver-mercury fillings? Yes No If so, how many and for how long? Do you have any root canals? Yes No If so, how many and for how long?
Have you ever been:a) Diagnosed with an illness? Yes No If so, please explain: b) Hospitalized? Yes No If so, for what reason:
Have you had surgery to remove your gall bladder? Tonsils? Appendix? If so, explain:
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Have you experienced fungal infections (Ex. Jock itch, Athlete’s foot)? Yes No If so, please describe: Have you experienced a decline in sexual interest? Yes No Have you had kidney stones or gallstones? Yes No If yes, please describe:
How often do you have a bowel movement daily? Do you strain to have a bowel movement? Yes No Occasionally Related to particular food or circumstance? Do you have loose bowel movements? Yes No Occasionally Related to particular food or circumstance? Is there undigested food in your stools? Yes No Occasionally Other bowel-related concerns? (Colour, blood, oily, etc.)
FAMILY HISTORY: Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for other(s):
Allergies Diabetes Intestinal Disease
Alcoholism Drug Abuse Kidney Dysfunction
Arthritis Gall Bladder Issues
Mental Illness
Asthma High Cholesterol
Osteoporosis
Autoimmune Disease
Heart Disease Skin Conditions
Cancer Hypertension Ulcers
Type(s) of Cancer: Other condition(s):
FEMALES:Are you pregnant? Yes No Are you currently breastfeeding? Yes No Have you noticed any changes in menses? (Ex. Frequency, duration, flow, clotting, etc.) Yes No If so, please specify: Do you suffer from PMS symptoms? Please specify: Are you pre-menopausal? Yes No Post-menopausal? Yes No Are you experiencing any menopausal symptoms? Yes No If yes, please specify: Have you had a bone density test? Yes No If yes, what was the result?
MALES:Have you experienced any prostate problems? (Ex. frequent urination, discomfort during urination) Yes No If yes, please describe:
NUTRITIONAL AND DIETARY HABITS:How many times a day do you eat, on average? Main meals: Times of day: Snacks: Times of day:
Provide examples of your typical meals and snacks:Breakfast: Lunch:
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Dinner: Snacks:
Do you eat: With family? Home alone? On the run? Restaurant? Fast food? Where do you commonly grocery shop? What percentage of meals/snacks consumed are homemade? In terms of preparing your own meals, what is your skill level in the kitchen? Please quantify on a scale of 1 (low) to 10 (high):
How many servings of each food type do you typically consume in a day? Fruit Fresh Frozen Canned Dried Vegetables Cooked Raw Frozen Canned Whole Grains Type: Protein Type: Dairy Type: Fats Type: Other Type(s):
Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”): Aluminum pans Artificial Sweeteners
Candy Cigarettes
Refined Foods (pastries, white pasta, etc.)
Fried Foods Luncheon Meats
Margarine Microwave
Fast Foods
Please indicate how many cups of the following you drink per day: Tap water Coffee Tea Soft drinks (diet) Soft drinks (regular) Fresh fruit juices Fruit juices (prepared) Milk Prepared vegetable juices
Fresh vegetable juices Red wine White wine Beer Other alcoholic beverages Bottled or spring water Herbal tea Other:
Do you currently follow a special diet? Yes No If yes, please explain: Do you avoid certain foods? Yes No If yes, list food(s) and reason why:
How often do you eat meat? Daily 3-5/week Once/week or less How often do you consume dairy? Daily 3-5/week Once/week or less
What’s your favourite food(s) and how often do you eat them? Which food(s) do you crave, and how often do you eat them? Do you experience any symptoms of meals are missed? Yes No Please explain: Do you experience any symptoms after meals? Yes No Please explain:
COMMENTS:
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Nutri-System Profile (NSP) Assessment FormPlease indicate if you’re experiencing any of the symptoms or activities below by indicating: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
General fatigue or weakness Varicose veins Difficulty losing weight Feeling out of control Frequent illness/infections Food/chemical sensitivities High stress lifestyle Frequent yeast/fungus problems Smoking Bones break easily, osteoporosis Drink more than 2 cups of coffee/day Too little exercise Bad breathe and/or body odour Excessive mucous Constipation Shortness of breath climbing stairs Bags under eyes Tingling in lips, fingers, arms, legs Craves sugar, bread, alcohol Chest pains Difficulty digesting certain foods Very rapid or slow heart beat Recent antibiotic use Painful, hard or thin bowel movements Allergies Alternating constipation/diarrhea Poor concentration or memory Recurrent bladder infections Belching or burping after meals Female: Menopause, hot flashes Skin/complexion problems Female: PMS Frequent consumption of red meat Difficult urination Regular use of dairy products Swollen glands, puffy throat Heavy alcohol consumption Lower abdominal pain Exposure to toxins/chemicals Frequent need to urinate Frequent mood swings Joint pain Depressed and/or irritable Sinus inflammation/discharge Brittle fingernails Arthritis Dry, brittle hair, split ends Sudden weight gain/loss High fat/high cholesterol diet Headache/Migraines Nervousness/anxiety/tension/worry Female: Taking birth control pills Insomnia, restless sleep Lower back pains Low fiber diet Dry, flaky skin Muscle cramps Drink less than 6 glasses of fluid/day Sleepy when sitting up Water retention Female: menstrual cramps Low sex drive Bronchitis/asthma//pneumonia/emphysema Feeling heavy/bloated after meals Cellulite Chronic cough Cold hands and feet
COMMENTS:
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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
THE DIGESTIVE SYSTEMExcessive gas, belching or burping after meals
Full feeling after heavy meat meal
Stomach bloated after eating Heavy, tired feeling after eating Sleepy after eating Nausea after taking supplements Longitudinal striations on fingernails Acne Eat when rushed/in a hurry Undigested food in the stool Bad breathe
Stomach pain 1 hour after eating or at night Sensation of acidity in abdominal area Burning sensation in stomach Heartburn, indigestion Pain aggravated by worry/tension Blood in stool Hiatal hernia Lower back pain Gastritis, gastric ulcer Long term aspirin use Nausea, vomiting
Yellow or pale fingernails Food allergies Skin oily on nose and forehead Irritable, easily angered Fats/greasy foods cause nausea, headaches Weight gain around the abdomen Vertical white streaks on fingernails Yellow palms Onions, cabbage, radishes, cucumbers cause bloating/gas
Jaundice
Bad breathe; bad taste in mouth Poor concentration Excess body odour Difficulty losing weight High cholesterol/high cholesterol diet Acne, boils, rashes, psoriasis or eczema Migraine headaches Constipation Discomfort underneath right ribcage
Gall stones; history of gallstones High cholesterol diet; high blood cholesterol levels
Stool appears clay-coloured, foul odoured Severe pain in right upper abdomen Constipation
Severe abdominal pain Fever Nausea and vomiting Alcohol addiction Slow digestion; feel full for hours after eating
Jaundice
Hungry up to 3 hours after eating Family history of diabetes Strong cravings for sweets, starches, coffee or alcohol
Fatigue
Nervous/anxious feelings relieved by eating Frequent headaches Irritable if late for or skip a meal Fainting spells Overweight Depression Addicted to pop and/or coffee with sugar Lose temper easily Frequent “midnight snacks”
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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
THE INTESTINAL SYSTEMExtreme fatigue Rectal itching Recurrent vaginal infections Abnormal muscle aches from exercise Frequent use of antibiotics Excessive wax in ears White coated tongue, oral thrush Unexpected/unexplained weight gain Craves sugars, bread, alcohol Impotence Headaches Canker sores Tonsillitis, recurrent strep throat Athlete’s foot, finger/toenail fungus,
ringworm
Itchy, watery or dry eyes Jock itch Skin flushes “Brain fog” Chronic indigestion, frequently use antacids Irritability Always cold, especially in extremities Memory loss Female: PMS Mental confusion Pain in pelvic area Depression or anger for no reason Abdominal gas and bloating Anxiety/panic attacks Loss of sex drive Inability to concentrate Cystitis, repeated bladder infection Phobic/compulsive Increasing food and chemical sensitivities Lethargy Female: Endometriosis/ ovary problems Mood swings Chronic diarrhea Itchy ears, nose, anus Hives, psoriasis, acne, skin rashes
Forgetfulness Pain in the back, thighs, shoulders Slow reflexes Numb hands Gas and bloating Drooling while sleeping Unclear thinking Damp lips at night Loss of appetite Dry lips during the day Yellowish or pale face Grind teeth while asleep Fast heartbeat Bedwetting Heart pin Lethargy; chronic fatigue Pain in navel Dark circles under eyes Eating more than normal but still feeling hungry
Cancer
Blurry or unclear vision Rectal itching
THE LYMPHATIC SYSTEMExcessive sleep Soreness on both sides of neck at shoulder Very susceptible to infections Feel puffiness in throat Swollen glands: tonsils, throat, armpits Look older than chronological age History of cancer, MS, Parkinson’s, arthritis Flu-like symptoms often occur Loss of appetite Lupus Headaches
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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
Acne, psoriasis, dermatitis, eczema Excessive sweating, night sweats Rapid pulse, heart irregularities Bowel disease: IBS, IBD, Crohn’s, etc. Frequent headaches Joint pains or stiffness Hay fever Frequent night urination Frequent cravings for certain foods Wheezing Periods of blurred vision Pale face Repeated ear trouble Hives Hyperactivity Nose runs constantly Dizzy spells Noticeable changes in writing throughout day Periods of confusion Nosebleeds Poor concentration Bloating or gas after eating certain foods Epilepsy Canker sores Muscle cramps or spasms Dark circles under eyes Abnormal body odour Stuffy nose
THE ENDOCRINE SYSTEMDistinct, lethargic tiredness or sluggishness Hair dry, brittle, dull, lifeless Cold hands or feet Flaky, dry rough skin Mercury amalgams (fillings) Feel stiff after sitting still for some time Gain weight easily, fail to lose on diets Mood swings Constipation, less than one bowel movement a day
Usually square and wide fingernails
Low energy in the morning High cholesterol Low pulse rate Low sex drive Low body temperature, especially bed rest
Losing weight without trying Insomnia Heart races while at rest Increased appetite Feel warm/flushed at room temperature Frequent bowel movements, diarrhea Hands shake or tremble Excessive sweating without exercising Protruding tongue Nervous behavior, hyperactivity Heart palpitations
Headaches affecting one side of head Excessive urination Female: Loss of menstrual function Pain in little finger of left hand Moody Swelling in ankles, fingers and/or feet Overweight from waist up Cold hands or feet Overweight from waist down Pain in left side of upper neck
Stress or emotional upset cause exhaustion Occasional cold sweats Dizzy/light-headed upon standing quickly from a lying or crouched position
Tightness or lump in throat, especially when emotionally disturbed
Sweat excessively High or low blood pressure Neck and/or shoulder tension/pain Rapid pulse Frequent headaches Short temper Bow lines (depressed furrows) on fingernails Puffy face
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PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
Forgetfulness, “brain fog” Low resistance to infections, catch cold/flu easily
Energy crash mid-afternoon (around 2-5pm) Difficulty falling or staying asleep Need to snack to help energy levels and cravings
Increased muscle soreness with similar physical activity level
Abdominal weight gain Female: Worsened PMS symptoms during menstrual cycle
Low sex drive or lack of interest Frequently wake up around 2-4pm, can’t fall back asleep
Anxiety, irritability, depression (mood swings)
Low stamina, energy and difficulty maintaining muscle mass
Decreased ability to deal with stress and deadlines
Low tolerance towards alcohol or caffeine
Strong carbohydrate or salt cravings Cold hands or feet/other extremities Hair loss Dry skin Significant improvements in stress levels during vacation or time away from work?
THE STRUCTURAL-MUSCULAR/SKELETAL SYSTEMPain, swelling, stiffness in joints Rounding of shoulders, stooping Joint inflammation (rheumatoid arthritis) Female: Menopause Pain, stiffness, inflammation of spine Pain in forearm or biceps Facial pain Cramps in calf muscle during sleep or
exercise
Joints making popping sounds Painful cramping in feet or toes Gout Teeth prone to decay; frequent toothaches Ankylosing spondylitis Malformation of bones Bones fracture easily Insomnia Gradual loss of height Muscles weak, weak grip, light objects feel
heavy
Tooth loss; teeth “falling out” Heart palpitations Lack of exercise Diet high in animal foods (meat, dairy, eggs)
Muscle pain Sprains; muscle strains Muscle weakness Muscle(s) spasm
Muscle wasting in some part of the body Tremors Numbness or loss of sensation Loss of peripheral vision Mood swings and/or depression Slurred speech Blurred or double vision Objects fall from hand, reach in wrong place Tingling and/or numbness, especially in extremities
Hands tremble
Muscular stiffness Impaired speech Male: Impotence Difficulty breathing
COMMENTS:
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Nutrient Deficiency TestPLEASE COMPLETE THE FOLLOWING TEST USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.
Excess fluid retention (edema) Nausea or dizziness Poor coordination General, overall weakness Anemia Cataracts Catch colds, flu, infections easily Cuticles tear easily Hair dull, dry, sparse, loose and falling
Rough, dry or scaly skin Dry, brittle hair Eczema Psoriasis Poor memory Irregular menstrual periods
Osteoporosis Bones break easily Irregular heart beat Brittle nails Muscle cramps Crowded teeth Insomnia
High blood cholesterol Intolerance to alcohol Diabetic or hypoglycemia Overweight Sugar cravings Chronic dieter Kidney disease
Fatigue, extreme lack of energy Dry hair Thyroid problems; goiter Overweight Constipation Cold hands or feet Brittle nails
Lack of energy or strength Dizziness Cravings for ice Pale lower eyelid Tachycardia Spoon shaped nails
Muscle spasms or tremors Gall stones Cravings for chocolate Irregular heartbeat Excessive body odour
Joint pains Bursitis, tendonitis Prone to injuries Weak knees Creaking or clicking of joints Weak muscles
High blood pressure Swelling of ankles Always thirsty Irregular heartbeat Muscular weakness and fatigue
Dry hair Thin hair Weak immunity; frequent infection Dandruff Cataracts
White spots on fingernails Acne Male: Poor sperm production Frequent infection Poor dream recall Cuts/wounds heal slowly Loss of sense of smell or taste Thinning hair Red stretch marks
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Hard little bumps around elbows Dry or rough skin Dry hair, acne Poor night vision; night blindness Susceptibility to respiratory infections Slow light to dark adaptation Eyes unable to produce tears Weak tooth enamel Dandruff
Fatigue Apathy, depression Loss of knee jerk response Irregular heartbeat GI disorders
Dry skin around nose and lips Cracks/sores in corner of mouth Bloodshot or itchy eyes Cataracts Eyes sensitive to light Abnormal hair loss Trembling painful and purplish-red tongue
Sore tongue Fatigue Loss of appetite Skin disorders Swelling of mouth Smooth tongue Mental confusion Loss of sense of humour Canker sores in mouth
Anemia Irritability or nervousness Insomnia, poor dream recall Sore thumbs, kidney stones Female: acne worse during menstruation
Female: morning sickness during pregnancy
Fatigue and weakness Lightheadedness or dizziness Heart palpitations Shortness of breath; chest pain Sore, red, glazed-looking tongue Irritability; inability to concentrate Ringing in ears (tinnitus) Nausea and diarrhea Memory loss, forgetfulness Poor coordination
Skin disorders Smooth and pale tongue Loss of appetite Pale fingernails Irregular heartbeat Severe depression Mild anemia Hair loss
High blood pressure High blood cholesterol Overweight Eczema Bleeding ulcer Disoriented, memory loss Difficulty losing weight
Paleness Sore red tongue Bleeding gums Diarrhea Insomnia Irritability Fatigue
Constipation General gastrointestinal disorders Premature greying Depression and irritability Fatigue Headache
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Abdominal pain Anorexia Nausea Burning feet Depression and irritability Headache Nervousness Purplish red tongue
Bleeding gums Urinary tract infections Abnormal nose bleeds Slow healing of wounds General weakness Shortness of breath Skin bruises easily Ruptured blood vessels in eyes Excessive hair loss Aching bones and joints
Muscle weakness Pain in ribs, spine, legs Malformation of bones Osteomalacia Osteoporosis Muscle cramps Rickets, insomnia Nearsightedness (myopia)
Heart disease Premature aging Weakness Irritability Diarrhea Poor skin condition Brittle hair Muscle wasting
COMMENTS:
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