Nutrition Lifestyle Intake Form

Lifestyle Assessment Form

This evaluation is designed to assess symptoms that may relate to nutritional imbalance. Its sole purpose is to educate and inform. It is not designed to diagnose diseases. If you suspect you have a problem that requires the attention of a medical practitioner, please see your physician or naturopath for medical care.

Please answer each of the following questions. If you require additional space, use the back of the page.

GENERAL INFORMATION

Name: Date:

Date of Birth: Marital Status: Number of Children:

What is the main reason you made an appointment to come here today?

What are your main health concerns in order of importance to you personally:

1.

2.

3.

How are you feeling?

What are you doing for your health presently? (check all that apply)

Exercise Vitamins Minerals Herbs

Chiropractor Prescription Medication Diet Meditation

Medical Doctor Relaxation Techniques Acupuncture

What do you believe or suspect might be the underlying factors contributing to your present health concerns?

Height: Weight:

Do you wish to:

Gain weight Lose weight

How much weight would you like to gain or lose?

How is your blood pressure?

What level of stress do you feel you are experiencing at this time in your life?

Minimal Average Considerable Unbearable

What are the major causes or factors of your stress? (check all that apply)

Financial Career Personal Marriage Health Family Spiritual

Unfulfilled Expectations Other:

How many hours do you sleep daily?

Do you wake feeling rested?

Yes No Sometimes

Describe your energy level?

How many hours a day do you work?

What type of work do you do?

Do you enjoy your work?

Yes No Sometimes

How many hours each day do you spend driving?

Do you smoke?

Yes No If yes, how much?

If no, are you often exposed to second-hand smoke?

Yes No

Describe what you do for exercise?

How many hours a day do you:

Watch television Read Spend in front of a computer?

What are your interests/hobbies?

Do you take vacations regularly?

Yes No

When was your last vacation?

How did you spend your last vacation?

Do you actively participate in a church or spiritual group?

Yes No

MEDICAL HISTORY

Are you currently taking any medication?

Yes No

List/Reason(s):

Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking and the amounts/dosage:

Do you have any allergies? If yes, please list:

Have you ever been:

Diagnosed with an illness? Explain:

Hospitalized? For what reason:

How often do you have a bowel movement?

Do you strain to have a bowel movement?

Yes No Sometimes

FAMILY HISTORY

Hereditary Diseases: Please indicate “F” for Father, “M” for Mother, “S” for Siblings, “G” for Grandparents, “O” for Other relatives.

Heart Disease Diabetes Allergies

Hypertension Arthritis Mental illness

Cancer Osteoporosis Intestinal disease

Other:

Have you ever been treated for drug and/or alcohol dependency?

Yes No

DIETARY HABITS

How many times a day do you eat:

Main meals What times of the day:

Snacks What times of the day:

On a typical day, what would you eat for:

Breakfast:

Lunch:

Dinner:

Snacks:

At what time do you have your last meal or snack of the day?

Do you eat or use: (check all that apply)

aluminum pans microwave margarine

candy fried foods refined/processed foods

luncheon meats cigarettes artificial sweetener

fast foods air fresheners scented body products

Please indicate how many cups of the following you drink per day or week

Are you: (check one)

A meat eater

Lacto-ovo-vegetarian - eat dairy, and eggs, but exclude animal flesh

Ovo-vegetarian - eat eggs, but no dairy or animal flesh

Lacto-vegetarian - eat dairy, but no eggs or animal flesh

Vegan - eat no animal foods of any type

Semi-vegetarian - eat dairy, eggs, poultry and fish, but avoid red meat

Flexi-tarian – eat dairy, eggs, fish and poultry, with some vegetarian meals

How often do you eat meat?

Daily 3-5 times week Once a week or less

How often do you consume dairy products?

Daily 3-5 times week Once a week or less

What are your favourite foods?

How often do you eat them?

What foods do you crave, if any?

Do you experience any symptoms if meals are missed? Explain:

Do you avoid certain foods? If so, what are they and why do you avoid them?

Do you experience any symptoms after meals? Explain:

Is there anything else about your health that you would like to share with me?

CLIENT STATEMENT

I understand and acknowledge that the services hereby provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnoses, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily. All information will be kept strictly confidential.

Today’s date:

Name (Please print):

Address:

E-mail:

5 Day Food Diary