Young Adult Questionnaire

Cynthia Dalton, MNT

Master Nutrition Therapist

YOUNG ADULT QUESTIONNAIRE

Name______Nickname______Today’s Date______

Address______

City ______State ______Zip Code______

Tel. No. ______Cell Phone No. ______Age____

Email ____________

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Health/Wellness Information:

Birthdate______Height______Weight______

Eye Color______Hair Color______Hair Texture______

Percentile (if known)______Blood Type (please circle) A B AB O Rh+ Rh-

Cholesterol (if known) LDL______HDL ______Triglycerides______

Pediatrician______

Location ______Telephone______

Psychiatrist(if applies)______

Location______Telephone______

Therapist (if applies)______

Location______Telephone______

Specialist____________

Location______Telephone______

Specialist____________

Location______Telephone______

Specialist____________

Location______Telephone______

Any Diagnosis ?____________

When?______

Who provided the diagnosis?______

What is the purpose for this visit? ______

______

When did this issue begin?______

______

OperationsInjuries

Approx. age when you had an
operation for: / AGE / Please describe any injuries / AGE
Appendix / Head injury
Tonsillectomy / Broken bone
Hernia / Broken bone
Adenoids / Eye injury
Neck injury
Abdominal injury
Other surgery (please list) / Other injury (please list)

Do you live with your parents or on your own?______

Who also lives with you?

Name______Age _____ Relationship______

Name______Age______Relationship______

What pets live with you? Indoor/Outdoor? ______

______

When and where have you lived or traveled outside theUnited States?______

______

Any recent major life changes? ______

______

Have you experienced any major losses in your life?______

______

Please describe your strengths, hobbies or unusual skills?______

______

Future aspirations? ______

______

Have you ever seen a Nutritionist before?_ Y ____ N_____ If Yes, when?______

What was the outcome?______

Have you ever seen an Allergist? Y___ No___ What tests were done?______

Outcome?______

______

Consultations, Tests or Treatments that you found most, or least, helpful.______

______

Overall Happiness:

Please rate yourlevel of happiness:(please circle, 1 being the most sad, 5 being the most happy):

1 2 3 4 5 Any comments you’d like to add? ______

______

Do you often feel anxious, angry, depressed? ______

Do you have trouble with focus or concentration? ______

General Health:

Please rate your overall level of wellness: (please circle, 1 being the worst).

1 2 3 4 5 Any comments you’d like to add? ______

______

Typical Sleeping Patterns:

Typical hours of sleep each night:______Any trouble falling asleep?______

Do you awake frequently during the night?______

Do you feel adequately rested?______

Bathroom Habits: (sorry about this one)

Do you have daily bowel movements? Yes____ No___ Please describe:_(formed, runny, pellets, dark, light)______

______

Energy Level:

Please rate yourenergy level (please circle, 1 being the lowest): 1 2 3 4 5

Do you feel like you have enough energy to get you through the day? Please describe:

______
______

Females Only: When did you begin your menstrual period?______

Do you have cramps, PMS, irregular periods, or any other concerns? ______

Environmental Exposure History:

Past / Present
Mold in bathroom/basement
Pest extermination – inside
Pest extermination – outside
Forced hot air heat
Had water in basement
Mold visible on exterior of house
Heavily wooded or damp surroundings
Moldy, musty school/day care
Tobacco smoke
Well water
Carpet in bedroom
Carpet in most parts of house
Feather or down bedding

Eating Habits:

Do you have a healthy diet? Y____ N____Not sure______

Typical mealtimes during the week?

Breakfast ______Lunch ______Dinner______Snacks______

Typical mealtimes during weekends?

Breakfast ______Lunch ______Dinner______Snacks______

How many times per week do you eat meals out?______

Do you eat fast food? ______Your favorite?______

How much liquid do you typically drink each day? ______cups or oz. (circle)

Milk _____Soda_____Diet Soda _____ Energy Drinks _____Juice_____ Water______

What are your favorite healthy foods?______

______

Least favorite healthy foods?______

Do you have any particular cravings?______

How many times a day do you eat sweets?______Favorite Sweet ?______

______

What foods would be a battle to give up?______

What foods would be easy to give up?______

LifeStyle Habits:

How much physical activity do you get in a typical day? ______

(pleasedescribe)______week?______

______

Do you have a water or air purifier? ______

Do you smoke cigarettes? ______if so, how much? ______

Do you drink alcohol? ______if so, what and how much/often?______

Any other illicit drug use?______

Other:

List the Frequency of Antibiotics (and condition) ______

______

Have you had all of your recommended vaccinations? ______

Any problems noted with vaccinations?______

How often do you get flu shots? ______

Have you had extensive dental work done? Braces? Crowns? Root canals? ______

Education:

Are you attending school or plan to attend school in the near future? ______

Any school concerns? ______

Are you able to perform at your potential (to your knowledge)? Y______N______

Any identified or suspected Learning Disabilities? ______

______Work History: (describe current, past of interest)______

______

Current medications, supplements: (continue on the back if needed)

______
______
______

______

List any prescribed medications taken in the past five years: (continue on the back if needed)

Condition ______Medication______Dosage______

Condition______Medication______Dosage______

Condition ______Medication______Dosage______

Medical History

Please check if you or your biological family members have had the following:

Self Family______More Info______

_______ Autism ______

______Arthritis

______Diabetes (Type I or Type II)______

______Headaches / Migraines______

______Heart disease______

______Thyroid Issues (Hypo, Hyper, AutoImmune) ______

______Endocrine Issues (Hormones) ______

______Celiac disease or wheat (gluten) sensitivity______

______Dairy Sensitivity______

______Asthma or other Allergies______

______Obesity______

______Yeast (Candida) Problem______

______Digestion Problems (vomiting, diarrhea, constipation)______

______Alcoholism_or Substance Abuse ______

______Hyperactivity or Attention Deficit Disorder______

______Anxiety or Mood Imbalances______

______Other Diagnosed Brain Disorders ______

______Learning Challenges, Dyslexia______

______Other Conditions:______You’re done! Thank you!

Confidential